HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 815 JOHNSON STREET 8/9/2019 Commonwealth of Massachusetts RECEIVE®
• City/Town of AUG p 9 20iq
System Pumping Record
Form 4 HEALTH DEPARTMENT
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 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.
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A. Facility Information, -�
1. System Location: 1.410%ght front of house, Left/Right rear of house,/ Ight si�ouseft
Right side of building, ' fit front of building, Left/Right rear of b1�f18mg, n e
Address
City/rown State Zip.Code
2. System Owner.
Name
Address(if different from location)
Citylrown State, Zip Coale
TelephoMfluniber t'
B. Pumping kdcord -
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) peptic Tank 3 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of tem: ---
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. - Location where contentswere disposed:
Lowell Waste Water`McJA
i
Sign We cfHaulwUDate
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