HomeMy WebLinkAboutSeptic Pumping Slip - 437 SALEM STREET 3/22/2016 Commonwealth Massachusetts "
= i own of
Q Pumping.
Form 4 TOWN OF NORTH/�,,I OVER
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. Infor tion
1. System Location: Left/Right front of hous , e /~ igh#�rear of hous,'"left/right side of house, Left/
Right side of building, Left/Right front of bul ing, Left/Right rear of building, Under deck
Address t ,/
City/Town State
zip Code
2. System Owner: )
Name'
Address(if different from location)
CitylTown ' State 1
Telephone Number
B. Pumping Record
1. Date of Pumping
p g Date 2. Quantity Pumped: Gallons ,
3. Type-of s stem:
Yp Y. ❑ Cesspools) Septic Tank E3 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
ILA-
6: System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati here contents were disposed:
ISign Lowell Waste Water
L4
a Hanle Date
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