HomeMy WebLinkAboutSeptic Pumping Slip - 1550 SALEM STREET 9/28/2016 Commonwealth of Massachusetts
C4/Town of
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System Pumping.Record
• Farm 4
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DEP has provided this form for use.by local Boards of Health. Other form's 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 farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority,
A. Facility Information
nt 1. System Location: Left/C0tftf Mouse eft!Right rear of Mouse, Left/right side of Mouse, Left/
Right side of building, Left/Right front of building, Left!Right rear of building, tinder deck
Address
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City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
�
..k:
Cityfrown State p
Telephone Number ;
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.B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: =
Date ,,. Gallons _
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank r
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
o
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtufe I Haule Date
t5formCdor.-06/03 System lumping Record Page 1 of 1