HomeMy WebLinkAbout- Septic Pumping Slip - 850 JOHNSON STREET 8/28/2018 5
Commonwealth of Massachusefts
RECEIVED
City/Town f .
M. 2f3 ?.018
SyMem Pumping. i�. r°°,� -� �,2R r�u AMMER
Form 4
CEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information'must be substantially the tame as than provided here. Before using.this form,check with your
local Board of Health to determine the forrin they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority,
A. Facift Inform' sition
1. System Location: Left/Right frant of house, Left/ I h'rear of hogs, , Left/right side off house, Left
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
Address _.
_mac.
City/rown state Zip Code
2. System Owner
Name`
Address(if different from location)
Cityf'1'own ' '. Sfatrw � -� � ,pZid�� ,
Telephone Number
t4
® Pumping
i M
1. Crate of Pumping nate 2. Qu6ntlty Pumped:
Gallons
3. Type-of system`: El Cesspool(s) ptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes 91, o if yes, was it cleaned? ® Yes ❑ No,
1
" 6. Condition of System,
6; System Pumped 6y:
Neil.Bateson ' F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7, dati` :yahre cantents•were disposed:
7_ S Lowell Waste Water
Sign B H ule date
f
15fgrmil.doc-06/03 system Pumping Record gage 1 of 9