HomeMy WebLinkAboutSeptic Pumping Slip - 719 JOHNSON STREET 8/26/2015 Commonwealth of Massachusetts
City/Town of
JJ
S 'tem Pumping g.Record 0 ?G15
Form 4
T(Yl
but the� ,'
DEP has provided this form for use.by local Boards of Health. Other form i'mai-b e'Ui&['
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
I System Location: Left/Right front of house, Left/Right rear of house, Left/0@�t side of house, Left/
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
City1rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Statt?/-Z, Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ty Pumped:
bate 2 Qua Gallons
3. Type-of systeft. ❑ Cesspool(s) O�Se�pficTa*nk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes F-1 No
5. Condition of. stem:
6.. System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca contents were disposed:
G S Lowell Waste Water
.JDD
D. 4-S
Sign qt HauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1