HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 815 JOHNSON STREET 10/5/2021 Commonwealth of Massachusetts
RECEIVED
City/Town of OCT 05
System Pumping Record H`qLT��G PAR MENTER
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may'be'used, but the
information must be substanti*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/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
Address
City/Town State Zip Code
2. System Owner
Name
Address(if different from location)
G4YTown StaL- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. =G,L
ere contents-were disposed:
Lowell Waste Water
sign we it Haul Date
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