HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 JOHNNY CAKE STREET 4/30/2020 : Commonwealth of Massachusetts RECENED
City/Town of APR 3 0 ZVO
System Pumping Record IoWNOTHp�AR Vi TO uv Y PER
Form 4 HEA
DEP has provided this form for use by local Boards of Health. Other forms may be*used,but the
information,must be substantiaW 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 g ear o ou . , Left/right side of house, Left/
Right side of building, Left/Right front of building, e /Rlg rear of building, Under deck
Address
City/Town V State Zip Code
2. System Owner. 1 ^
Name"
Address or different from location)
C' own -`` Zip� state Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Locationhere contents were disposed:
L S Lowell Waste Water
Sign a Haul Date
t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1