HomeMy WebLinkAboutSeptic Pumping Slip - 1432 SALEM STREET 5/17/2016 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 M ht fr®f hous , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address (
city/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown State;. 1 � Zip Code ;
Telephone Number
l:
B. Pumping Record �.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 0-8-e-p-fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
*eHaule Lowell Waste Water
S Date
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