HomeMy WebLinkAboutSeptic Pumping Slip - 767 JOHNSON STREET 7/23/2018 r Commonwealth of Massachusetts `4h Nf NUU �iryrUrAo V ED a
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•EA lid§-Record 7OWN OF WX
®EP has provided this for,M for use-by lel Boards 6f,Nealth.Other forms may be'used,but the
information-must be substantially the tame as that provided here. Before using.this for rn,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.
cflrmiation
1. System Location; Left/Right front of house, Left/Right rear of houswfG right _.. .use;Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Gity/`rown state Zip Cotte
2. System Owner:
PJame
Address(if different from location)
city/Town State �� _ Zip Code
Telephone(Number
Pumpingit
1. Date of Pumping ( � 2. Quanfi Pumped:
f '----
p g Date P Gallons
3. Type-of s stern":
yp y. El Cesspool(s) Septic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter present'? [j Yep 0160 if yes, was it cleaned? E Yes El No
5. I
Condition of Sy fir `, -C �w(✓t, _ �� .
6. System Pumped By:
Nell.Bateson • P5821
{Name Vehicle License Number
Bateson_Enterprises Inc'
Company t
7. Location more contentewere disposed:
L Lowell Waste Water
' F
4SIgnhui Date
tMrmd•.doc•06/03 system Pumping Record•Page 1 of 1