HomeMy WebLinkAboutSeptic Pumping Slip - 492 SALEM STREET 5/19/2016 Commonwealth
i own of .
• f i Record RECEIVED
$a
Form 4
DE.P has provided this form for use-by local Boards of Health. Other forms may Ut � )vER
information must be substantially the same as that provided here. Before using.this fbr-&'f" I " with your
local Board of Health to determine the farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Locatio . Rigt front of hous ;,Left/Right rear of house, Left/right side of house, Left/
Right side of but ding, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name*
Address(if different from location)
Citylrown ' State zip Code
Telephone Number
r. J
. Pumping ecor
1. Date of Pumping oats 2. Quantity Pumped:
Gallons ,
3. Type-of system: ❑ Cesspool(s) O— eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes o 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. Locati n-v hj re contents were disposed:
i.
Lowell Waste Water
SignAtu a Haule Date
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