HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 981 JOHNSON STREET 10/16/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left f tide of h house eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under3eck
Address
1 -�\ tv � G7 N . ��
CiWTown - State Zip Code
2: System Owner.
. [77ff
Name
Address(if different from location)
Citylrown State Zip Code
(10n-� - 1CIF&- b
Telephone Number
B. Pumping Record G
1. Date of Pumping Date t 2 uantity Pumped:
Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
�c - ( %
ASignibite cfoHaut Date
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