HomeMy WebLinkAboutSeptic Pumping Slip - 1187 SALEM STREET 4/11/2016 Commonwealth of Ma
- i own of
e Y item Pumping.Record
Form 4 i�ai ��.�a�i)D'�,J,i ME!',!T
DEP has provided this form for use-by focal Boards®f 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 Locatia�i Rig ont of hou eft/Right rear of house, Left/right side of house, Left/
Right side of bul ing, Left/ tg ro=t of building, Left/Right rear of building, Under deck
Address )
tea. •. � � �
City/Town State Zip Code
2. System owner:
4x- Oix�
Name
Address(if different from location)
Cityrrown ' State
% Zip Cade
Telephone ber
y
B. Pumping Record
1. Date of Pumping antit
Date 2. Quy Pumped: Ganons
.,,..
3. Type-of system: El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑—N-6-- 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. Location where contents were disposed:
Lowell Waste Water
Lr
m . a
-SIgngtufe cf Haule Gate f
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