HomeMy WebLinkAboutSeptic Pumping Slip - 264 JOHNSON STREET 11/17/2015 Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
Form 4
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 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 n ht side of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
. Address � ,,,-� \1 � ` �``'�.�'���'-t°��." �7•�_ �C�°�`��'`,� C.7�'`
City/Town State Zip Code
2. System Owner.
A
Name'
Address(if different from location)
Citylrown State Qode
Telephone Number
B. Pumping Record ,
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes EY No If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatip ere contents-were disposed:
L S Lowell Waste Water
Sign a 9t Haule Date
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