HomeMy WebLinkAboutSeptic Pumping Slip - 1187 SALEM STREET 10/21/2016 Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4
DEP has provided this form for 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.thls form,check with your
local Board of Health to determine the form they use.The System Bumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information,
1. System Location: k e��tr .l.'tigh o t fho e, Left I 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
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
city/rown ' Mat ..e` zip Code
Telephone Number +'
.B. Pumping JRpcord
t
1. Date of Pumping pate 2. Quantity Pumped: Gallons .`
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ® If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition ofSyste .'
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Ehte!prises Inc'
Company
!' 7. Loco' n,w ere contents were disposed:
-;
&_" Lowell Waste Wa#er
Sigle Date
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