HomeMy WebLinkAboutSeptic Pumping Slip - 100 JOHNNY CAKE STREET 12/14/2017 Commonwealth of Massachusetts
CitWTown of .
System Pumping.Record
Form 4.
DEP has provided this form for use-by local Boards of Health. Other forms maybe*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 to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left 1 Right rear of house,�Ight69801� , Left/
Right side of building, Left 1 Right€rant of buildirig, Left/Right rear df bull ding, Under deck
Address
City/rown State - Zip Code
2. System owner:
Name' ..� .,.,. _...
Address(if different from location)
Citylrawn State-
Telephone
tateTelephone Number
.B. Pumping record
4. Date of Pumping bate Quantify Pumped' Daltons r
I Type-of system: ❑ Cesspool(s) eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present'? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No;
5. Condition of System F
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati here contents-were disposed:
IS19nn
Lowell Waste Water
Haul Date
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