HomeMy WebLinkAboutSeptic Pumping Slip - 150 JOHNNY CAKE STREET 10/15/2015 l
Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
Form 4
DEP has provided this form far 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 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/ i ht rear of houseL.eft/right side of house, Left/
Right side of building, Left/Right front of building, Left Ig ar o building, Under deck
Address _. . ..
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Ci !Town
ty State 9 Zip Code
Telephone Number r
B. Pumping Record �.
1. Date of Pumping 2. Quantity Pumped:
Date Gallons �T
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? r® es ❑ No,
' 5. Condition of.System,
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L SZ Lowell Waste Water
MOA41
SignAhle I Haule date
. I
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