HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 100 JOHNNY CAKE STREET 1/14/2021 Commonwealth of Massachusetts
_ City/Town of JAN 14 2021
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 hous. , Left Ag h�de oT ho su a .eft/
Right side of building, Left/Right front of building, Left/Right rear of in Un er ec
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown State
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 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: L�� -��
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents-were disposed:
G L S-P Lowell Waste Water
Sign a Haut Date
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