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HomeMy WebLinkAboutSeptic Pumping Slip - 815 JOHNSON STREET 11/28/2017 Commonwealth of Massachusetts g�orv�� tvv . E, City/Tawn of ° SyStem Pumping-Recordov- �-`... Form DEP has provided this form for use-by local Boards of Health. Other form's may�be`used, but the Information,must be substantially the same 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 t© the local Board of Health or other approving authority. A. Facility. Information 1, System Location: Left/Right front tf House, Left/Right rear of haus. e •/righ sl of house„ eft/ Right side of building, Left/Right front of building, heft/Right rear of building, Undii_ e'q_ Address ,.. " ,�-r CtQ d.✓�"y� City/Town State Zip co;; 2. System Owner: Name' Address(if different from locatiori Cityrrown State Zip Code Telephone Number � 3 . Pumping•Record t,l •_ � � t"'� �'act:•' 1. Bate of Pumping Date Quantity Pumped: Dai — —}----- lons 3. Type-of system: ElCesspool(s) Septic Tank ❑ Tight Tank i ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes [( No 5. Condition of.System: 6: System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc, Company 7. Loca' ikw ere contents-were disposed: 1 GLS: Lowell Waste Water vig­nitufe Haul Date t5form4.doc•06103 System Pumping Record•Page 9 of 1