HomeMy WebLinkAboutSeptic Pumping Slip - 50 JOHNNY CAKE STREET 12/13/2017 _ Commonwealth of Massachusefits
Y UWTown of .
System Pumping-Record
Form 4
DEP has provided this form far usesby total Boards i�f Health. Other forms 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 farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility inform' ation-
1. System Location: Left/Right front of house, Righ ar of h6u_s , Left/right side of house, Left J
Right side of building, Left 1 Right front of buirwag, Left 1 Right rear of building, Under deck
-
Address
Cityrrown _ _ State Zip Code
Z System Owner:
Name'
Address(if different from location)
CitylTown ' State � � Zi Cod ;
F
Telephone Number
.B. Pumping record
-7
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-Of system: ® Cesspool(s) eptic Tanis ® Tight Tank ;
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ulc:ense Number
Bateson Enterprises Inc,
Company
7. Lo n contents-were disposed:
GL S: Lowell Waste Wafer
. F
Sign tufe HgulwU tate
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