HomeMy WebLinkAboutSeptic Pumping Slip - 507 SALEM STREET 10/12/2016 Commlonwealth of Massachusetts ECrEI ��°�D
City/Town of .
S stem Pumping-Record `
"MN OF�,nRrH ANEMER
Form 4
DEP has provided this form far use by 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 Locatio Ln aMightli t_ ouse,,Ieft/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 `� p�")��,�'„���...�., ��"` �,,/�1,�"�'�f`✓'',�- � -'�-1`Qv`�"
CitylTown State Zip Code
Z. System Owner.
Name'
Address(if different from location)
City/Town ' State (gyp Code
t
t
Telephone Number —[ (74" ;y +
r
.B. Pumping R mword
( C
1. Date of Pumping pate 2• Quantity Pumped: canons
3. Type-of system: ❑ Cesspool(s) 0"Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System
6: System Pumped By:
Neil.Bateson ' F5821 Li
Name Vehicle cense Number
Bateson Enterprises Inc
Company
7. L5eHoul tent&were disposed:
Lowell Waste Wate r Si mate
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