HomeMy WebLinkAboutSeptic Pumping Slip - 1132 SALEM STREET 10/18/2016 Commonwealth of Massachusetts
.
City/Town of
System Pumping-Record
Form
DEP has provided this form for use-by focal 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 Inforimr ation
1. System Location: Left/Right front of house, Left]Right rear of house, Left/ -
eft/ sloe of house;Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' State. Zip Code
Telephone Number +"Yd
i l
B. Pumping Record
1. Date of Pumping Sate 2. Quantity Pumped: canons —
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio re contents were disposed:
LS'LSQ Lowell Waste Water
Sign a Himle Date
t5formCom-06/03 System Pumping Record•Page 1 of 1