HomeMy WebLinkAbout- Septic Pumping Slip - 939 JOHNSON STREET 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumpling Record
Form 4
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DEP has provided this form for use-by local Boards of Health. Other forms m1061' US dt N t the
information-must be substantially the same as that provided here. Before using.this form,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 1qkjIghtE T11G1qq1n'1tt0f1 Mouse eft/Right rear of.house, Left-/right side of house, Left I
L. t ion
0 U"d
Right side of building, ulldifig, Left/Right rear of building, Under deck
Address
Lll Utz-�
cityfrown State Zip Code
2. System Owner A-4-A-
Name
Address(if different from location)
cityrrown Stater Zip Code
Telephone Number
Pumpling Record
P
1. Date of Pumping Date Oubrififir-Pumped: Gallons
3. Type•of system: Ej Cesspool(s) 9-t_epiic Tank D Tight Tank
0 Other(describe):
4. Effluent Tee Filter present.? El Yes a_60� If yes, was it cleaned? E3 Yes [I No
5. Condition of System, J\�,p AA-xrj
6. System Pumped J13
Nell.Bates7bn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Maul Date L/
tMrm4.doo-08/03 System Pumping Record m Page 1 of 9