HomeMy WebLinkAboutSeptic Pumping Slip - 815 JOHNSON STREET 11/21/2017 Commonwealth of Massachusetts RECEIVED
:1tY/Town of .
.oystem Pumpinecor �(111g-
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Ford 4• WN i. 1 i D :1Aii::t'TMENT
DEP has provided this form for use-by local Boards of Health. Other form's maybe'used, but the
information,must be substantially the-tame as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of Mouse, Leff/Right rear of house, Left9_ 612e of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
C frown
qty State Zip Code 1
2. System Owner.
Name'
Address(if different from location)
cityfrown '
State, Zi code
Telephone Number
Pumping JRecord
@m -
1. Gate of Pumping• g Date 2• Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) ❑peptic Tank ❑ Tight Tank
❑ Other(describe):
_..._ 1
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ❑ No,
' 5. Condition of System:
.'
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Ehterprises Inc, J
Company i
1. Locatio * '.a contents-were disposed:
., G�-S: Lowell Waste Water
Sign a Haul Date
t5farm4.do(.-06/03 System Pumping Record•Page 9 of 4
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