HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 990 JOHNSON STREET 2/27/2022 REGEIVEO
: Commonwealth of Massachusetts tiI 2022
CIR
Cityfrown of FE8
b �. �H ANpONO
System Pumping Record 1000oft10511VaossV
Form 4 HEA&JH
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 you
local Board of Health to determine the form they use.The.System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Informi�ation
1. S . tlon: Left/Right front pf house, Left/Right rear of houslr, Left/right side of house Left
Right id f building,
Left/Right front of building, Left/Right rear df building, Under deck
on the computer, ,,_ ,��
use only the tab
key to move your Addres
cursor-do not PV0 jJ MA A,
use the return -City/Town State Zip Code
key.
2. Sy tem Owner:
� c
ame
Address(if different from location)
MA
Cityfrown SIN �� Ch ip .Code
Telephone Number (7.9
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ' ' of co pone t pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Loc where contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date
i