HomeMy WebLinkAboutSeptic Pumping Slip - 1514 SALEM STREET 6/16/2016 Commonwealth f Massachusetts
City/Town ® .
RECEIVED
System Pumping,Record
Form 4
IUII' ;' ` ! `
Information must be substantial) the tame as that provided here. Before usih lh�fob;`rah
DEP has provided this fora for usezb local Boards of Health. Other formsr _
y p �" k 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.
Facilit Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left x6j si a of h uo shy Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address
CA
.m
City/Town State Zip Code
2. System Owner. ;
Name.
Address(if different from location)
a
City/Town ' State - Z'
• F
Telephone Number
B. Pumping Record ,
1. Date of Pumping 2. Quantity Pumped:
Date Gallons —�
3. TypeW system: Cesspools) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys em:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati hie contents were disposed:
GLS-Q Lowell Waste Water
Sign a Houle Date
t5form4.doc^06/03 System Pumping Record•Page 1 of 1