HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 147 JOHNNY CAKE STREET 4/28/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 2 8 2 Q 21
System Pumping Record
F NORTH ANDUVE:
Form 4 T�HEAWN LTH DEPARTMENT
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 housel;Ie ttgh r� ; Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/high rear of buitd'mg, Under deck
Address
CitylTown State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWown Sta �,p I
t C f
Telephone Number
B. Pumping Record _
( l
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesI 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. Location where contents were disposed:
G L S. \! Lowell Waste Water
S ign a 4 Haul WDate
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