HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 991 JOHNSON STREET 7/19/2021 Commonwealth of Massachusetts RE�E�vE�
City/Town of
System Pumping Record pFNORj"ZM SR
Form 4
DEf has provided this form for us&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 R"/Rig
e, Left/right side of house, LeftRight side of building, Left/Right front of building eft t rear of build'mg, Under deck
Address q� j -10
AAV
City/Town `-�, 6 State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State q;qP CcTelephone Number �J
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) [-S p c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 5-V ❑ No If yes,was it cleaned? [des-❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. 7GL
e contents-were disposed:
S Lowell Waste Water
Sign We qt li-buivu Date
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