HomeMy WebLinkAbout- Septic Pumping Slip - 1000 JOHNSON STREET 8/28/2018 Commonwea
usetts
Its of h � ° „r,,,�" ` "m
C i � wn of .
AUG 2 8 Z018
Syitem Pumping,Record
iw9 �V 6 i EIPARR I` E IT
DEP has provided this farm`for use-by local Boards of Health. Other farms may used,but the
information,must be substantially the tame as that provided here. Before using.this farm,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. lMation
1. System Location: Le./Right front of hous a ,C Igh rer 8f hogs , Left/right side of house, Left f
Right side of building, Left/Riga front of bui ing, Left/Right rear(if building, Under deck
Address p ��-,�'n�,� �--.-`�.:="jt � - �'�� �. - S�.}•,/,,.�',,r'-'-•
cityrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
city/Town ` State,/. Zi
��,.�`�`✓ ,.
Telephone Number
Pumping Rger .
1. Cate of pumping cote --- — 2, Quantity Pumped: Gallons
3. Type-of systerri: ® Cesspool(s) eptic Tank Tight Tank t.
(j tither(describe):
4. Effluent Tee Filter present? Yes r No if yes, was it cleaned? ® Yes ❑ No,
' 5. Condition of System: µ
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Phterprises Inc-
Company
7. Laotian ere contents-were disposed:
Lowell Waste Water
' � F
4Sjlq9nAWW-Haule
date
t5form4.doe-06/03 System Pumping Record a Page 7 of 1