HomeMy WebLinkAboutSeptic Tank & Pump Tank - Septic Pumping Slip - 815 JOHNSON STREET 10/5/2021 RECENED
Commonwealth of Massachusetts oCT p 2021
City/Town of
S stem Pum in Record 10001 DEPAR R
y P 9 H�
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio Right front of hoes�Le�Right a ous Left/right side of house, Left
Right side of buil , Left/Right front of bt elhga, Left/ g t rear of building, Under deck
Address
CWrown State Zip Coda
2. System Owner.
Name
Address(if different from location)
CiWown State Zip Coda
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) &i- eptic Tank ❑ Tight Tank
Cher(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped B r
- � F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents-were disposed:
_L S Lowell Waste Water
- "d —C( -a3��
Sign let Date
5form4.doc 06/03 System Pumping Record•Page 1 of 7