HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 125 JOHNNY CAKE STREET 4/9/2021 .&\- Commonwealth of Massachusetts
City/Town of
System Pumping Record PR 07 2021
Form 4
DEP has provided this form for use-.by local Boards of Health. Other forms may be used,but 4 T H
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/ 'ght earear�of h use a,Lef./right side of house, Left
Right side of building, Left/Right front of building, i_e g rear of building, Under deck
Address �C-� S- V Q rl V� �'� ,� P.
Cityfrown state Zip Code
2. System Owner.
Name"
Address(i different from location)
City/Town Stafe--3 r f a Trp Code
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 L i- 40 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. Loca' ere contents were disposed:
06Ha
Lowell Waste Water
Signul 0
WU Date
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