HomeMy WebLinkAbout- Septic Pumping Slip - 953 JOHNSON STREET 11/26/2018 Commonwealth of Massachusetts
City/Town of .
System Pumping Record
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DEF 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 fonn,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 Information
1. System Location: Left/Right front of House, Left/Right rear of house, Left 1 Jhf '[cT 0fY6@ Left
Right side of building, Left 1 Right fr®nt of building, Left I Right rear of building, Unbar cc
Address
.e
city/Town State Zip Code
2. System Owner:
Name
Address(if different from Iooatlon)
City/Town State- Zip Code
'telephone Plumber
B. Pumping Kocf
1. bate of Pumping 2. Quantity Pumped:
Date Gallons
3. Type�of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Bell.Sateson F5621
Name Vehicle License Number
Sateson Enterprises inc-
Company
7. Locat€ t where contents.were disposed:
C Lowell Waste Water
Sign a Hiul Date
t5fbrm4.doc^08/03 System pumping Record page 1 of 1