HomeMy WebLinkAboutSeptic Pumping Slip - 507 SALEM STREET 7/21/2016 Commonwealth fy� ,� b
City/Town of �
M.
° System u in g
Form 4
k
®EP has provided this form for use*by local Boards of Health. Other forms maybe bsed, bue
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 eft/ gW ....,, .. ., .,
y Le Ri h rant ref hou�se�, Left/Right rear of house, Left/right side of house, Left/
Right side of F fr®nt of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System owner:
Name , .
Address(if different from location)
City/Town '
State
Telephone Number
Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons °T
3. Type of system: ® Cesspool(s) �p tc Tank
El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑"No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
IA,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo om� }h re contents were disposed:
PS. Lowell Waste Water
Sign Cate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1