HomeMy WebLinkAboutSeptic Pumping Slip - 851 JOHNSON STREET 6/6/2018 RECEIVED
Commonwealth of Massachusetts
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DBP 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 forrh they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority,
. Facility, 1 ti
1. System Location: Laflk/Right front of douse Rt ' e r of ho Left/right side of house, Left 1
Right side of building, Left/Riga front of building, Le g r of building, Under deck
Address ` -
cityrtown state Zip Code
2.. System Owner:
Name'
Address Of different from location)
cltyrrown ' state t c r -7
`telephone Number
m t .
B.
Pumping
Record
1. Gate of Pumping Date 2 (quantity Pumped:
Gallons
3, Type-of s stern: /
yp y. ❑ Cesspool(s) IC Tank. El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yep o If yes, was it cleaned? ® Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neff Bateson ' F'5621
Name Vehicle License Number
Bateson Bate rises Inc
company
7. Loca contents were disposed:
PL S: Lowell Waste Water
aPgn a Fthula Date
t form4.doc-06/03 System Pumping Record.Fuge 1 of 1