HomeMy WebLinkAboutMiscellaneous - 990 JOHNSON STREET 4/30/2018 (3)� Commonwealth of Massachusetts
City/Town of
W° System Pumping Record,'
Form 4 (`AAy �(yJ / 11
%IM i ! U V 4 U L U 1 1
DEP has provided this form for use by local Boards of Health. Other fo s may be used, but the
information must be substantially the same as that provided here. Bef �0�ilag)#ftA qr,�f R ith your
local Board of Health to determine the form they use. The System Pu 147IMERAW i ub itted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, side of hoes flight side of house, Left
rear of house, right rear of house, left side of building, right rear o wading, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State /7 � _tom �.J C� Code
Telephone Number
JC y`— t
Date 2. Quantity Pumped
Cesspool(s) Septic Tank
C�
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes D' No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L.S. Lowell Waste.Watet
Signature of
t5form4.doc• 06/03
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1