HomeMy WebLinkAboutSeptic tank - Septic Pumping Slip - 91 JOHNNY CAKE STREET 8/16/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record AUG � 6 ZaZ�
Form 4c, rv,r .rru ++ e
DEP 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 of ho , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Andress �r ( 1C�� \✓�ti1_ ��=c1�,� /li�� ,►�
C4yfrown �J State Zip Code
2. System Owner.
Name 114
Address(ir different from location)
CitylTown State Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Qu tity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_N o 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' re contents were disposed:
GLLS-P Lowell Waste Water
Sign a qt WHaudl - Date
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