HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 805 JOHNSON STREET 11/26/2019 Commonwealth of Massachusetts RECEIVED
City/Town of NOv 2 6 �019
System Pumping Record ZOWN�FNCR�HANDU�ER
Form 4 NASA-v oEPARTMES
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/ ht rear of hous eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/ g rear of building, Under deck
Address
CityfTown State Zip Code
2 System Owner.
Name '—
Address(if different from location)
CityfTown state Zip Code
_ ��5�
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo 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. Lo re contents,were disposed:
G L S. i Lowell Waste Water
Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1