HomeMy WebLinkAbout- Septic Pumping Slip - 100 JOHNNY CAKE STREET 1/7/2019 Commonwealth of Massachusetts
City/Town Of
System Pumpling Record
Form 4
DEP has provided this form for use>by local Boards of Wealth. Other forms may be'used, but the
information,must be substantially the same as that provided Mere. Before using.this form,check with your
local Board of Health to determine the fora they use.The;System Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Factlity Infor Mation
1. System Location: Loh/Right front of Mouse, Left/Right rear of house, Pitin_/g.
gh ide f house eft 1
Right side of building, Left/Right front of building, Left/Right rear of bu Under eo
Address
City/rown state Zip Code
2'. System Owner: M
Name*
Address Of different from location)
CityTrown state Zi Code
telephone Number
Pumping e r
9. ®ate of Pumping Date 2. (quantity Pumped: Gallons
3. Type-of system: Ej Cesspool(s) asepti6Tank E) Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ej Yes o If yes, was it cleaned? ® Yes ❑ No
6. Condition of System: ^,i t � � r'"J � V\-
. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo ti re contents-were disposed:
L S Lowell Waste Water
sign a Hbui Cate
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