HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 JOHNNY CAKE STREET 4/9/2021 q7Z
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Commonwealth of Massachusetts APR V 2021
City/Town of
ARD HEALTH
System Pumping Record O OF
Form 4
DEP has provided this form for usez 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 forrh 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, Leftinht rear of hmi go.- - Left./right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
c7rWrown State Zip Code
2. System Owner. CIA
Name
Address(if different from location)
civrown Stat C)
Telephone Number
B. Pumping Record
1. Date of Pumping Quantity Pumped:
Date Gallons
3. Type of system. F-1 Cesspool(s) aSeptic Tank F-1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [DY'-e-s E] No If yes, was it cleaned? No
5. Condition of SystEm
6. System Pumped By:
Neil.Bateshn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G LS-P Lowell Waste Water
Sign fHaul
mu Date
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