HomeMy WebLinkAbout- Septic Pumping Slip - 991 JOHNSON STREET 10/19/2018 Commonwealth f Massachusetts RECEIVED
u
system t Record t, i
DEP has provided this form for use-by local Boards of'Health. Other forms may be'used,but the
Information.must be substantially the same as that provided here. Before using.this form,check with your
loc6l 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. t
A. Facility Inf®rm' aflon
1. System Location: Left/Right front of douse, Le . ►�ofLeft/right side of house, Left I
Flight side of building, Left/Rigiit front of buiidinia. Leuilding, Under deck
City/'rown state Zip Code
2. System Owner �%t1 V-\
pf�me
Address Of different from location)
Citylrawn State-
C' c„
Telephone plumber
. Pumping Record
1. Date of Pumping rate 2. Quantity Pumped: Gallons
3. Type-of system: [l Cesspool(s) lc('ank ® Tight Tank
Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? s' No
5. Condition of Sy trr� �,✓ c�� � � u�,„
6. .System Pumped By:
Neil.Sateson F5321
Name Vehicle License plumber
Sateso i Enterprises Incr
Company
7. Loca` w _ e contents-were disposed:
Q,L Lowell Waste Water
Is Hbule Cate
t5form4.doc-06/03 system Pumping Record e Page 1 of 1