HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 100 JOHNNY CAKE STREET 11/26/2019 Commonwealth of Massachusetts RECEIVED
City/Town of NOV 2 5 Z019
System Pumping Record rowN of
MENT
Form 4 HE,LTH
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 hous. , L nigh ide of ho , Left/
Right side of building, Left/Right front of building, Left/Right rear of bui ding, Un e c
Address
City/Tom State Zip Code
2. System Owner. -�
Name"
Address(if different from location)
CivTown Zip Code
�4
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 0--s'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes D_90_ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
JOC�s
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle t_icense Number
Bateson Enterprises Ina
Company
7. Lo a contents-were disposed:
G L S Lowell Waste Water
signit4e CfHgulwDate
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