HomeMy WebLinkAbout- Septic Pumping Slip - 950 JOHNSON STREET 11/26/2018 Commonwealth of Massachusetts
WCity/Town ofER
System Pumplono Record
-:.
Form 4
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 hare. Before using.this form,Check with your
local Board of Health to determine the forrh they use. Tice System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility f r t'r
1. System Location: Left/Right front of douse, Left/Flight rear of house, Left I right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ._
City/town State Zip Code
2. System Owner:
Name'
Address(if different from location)
CitylTown State Zip Code
'telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: EI Cesspool(s) E 9 S ept c Tank right Tank
® tither(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it Cleaned? ❑ Yes El No
6. Condition of System:
6, System Pumped By:
Nell.Batesnn F"5821
Name Vehicle License Number
Sateson Ehterprises Ina
Company
7.jSign
erg contents-were disposed:
: Lowell Waste Water
Neufe Date
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