HomeMy WebLinkAboutSeptic Pumping Slip - 1641 SALEM STREET 9/12/2016 Commonwealth of Massachusetts ED
City/Town of
Sy' tem Pump ing-Record
Form 4
DEP has provided this form for usefrby 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 tR front of lions�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
t
b("
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown State C' Zip Code
Telephone Number i
i
.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: — --�—�
Date daiions r
3. Type-of system: ❑ Cesspool(s) [1] is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ®—No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste (,
-. T,
jz_.
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo tiotwhre contents were disposed:
G L S: Lowell Waste Water
re �(('� F
Sjgin—A11ufK.cf Haute Date
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