HomeMy WebLinkAboutSeptic Pumping Slip - 990 JOHNSON STREET 7/2/2018 •CommonwelialthMassachusetts
RECEIVED
w City/Town of
¢u
Form
6 ii^ O ,T ANDOW
DEP has provided this forrri for use-by local Boards 'of-Health. Other forge maybe*used,but the
lnformation�must be substantially the tame 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 tc)
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of houso e ht t .f house eft l
Right side of building, Left I Right front of buildirig, Left/Right rear of ullding, Under eck
Address
City/Town state Zip Code
2. System Owner.
Noma
Address(if different from location)
CityfTown stater/-) ; Co} C %( 3
ti 'telephone Number
f
Pqmping Rqcord
1. bate of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9-No' If yes, was it cleaned? ® Yes NQ
5. Condition of System:
.
6. System Pumped By:
Neil.Batesbo ' F6821
Name Vehicle License Number
_Bateson Ehterprises Ina
Company
7. Location where contents-were disposed:
M L S.Q Lowell Waste Water
Sign a Haul pate
15farm4.doc•06/03 system Pumping Record 4 Page 1 of 1