HomeMy WebLinkAbout- Septic Pumping Slip - 915 JOHNSON STREET 1/7/2019 Commonwealth of Massachusetts
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City/Town of
System umplat �c°vt� �r�
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Form 4 �6f Al C 6�)[' /` ����,i-C
DER has provided this form for use=by local Boards of Health. Other forms may be bled, but the
information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine fe form they use. The System pumping Record must be,submitted to
the local Board of Health or other approving authority.
A. Facility I for i
1. System Location: Left t ht front of�okus Left/Right rear of house, Left/right side of house, Left I
Right side of building, Left ight roniidiri , Left/Right rear of building, Under deck
Address
city/town State Zip Code
Z. System Owner
Name.
Address(if different from location)
City/rown State Zi Coda
Telephone Number
Pumping ec
1. date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type-of system: E] Cesspool(s) eptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes ® No
5. Condition of System:
6. System Pumped By:
Neil.Bates7on P5821
Name Vehicle LPcanse Number
_Bateson Enterprises Inc
Company
7. Locati here contents-were disposed:
CD L Lowell Waste Water
SigntufaI Hhnle mate
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