HomeMy WebLinkAboutSeptic Pumping Slip - 1276 SALEM STREET 11/9/2016 Commonwealth of Massachusetts
C ty/Town of NOV 15 20m
System Pumping-Record
r Form 4 HEALTH DEPARTMENT
a
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.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/Right front of house( J Righ-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
City/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/rown State Zip Code
Telephone Number
.B. Pumping Record
1. date of Pumping Date uantity Pumped:
Gallons t^'
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ;.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye, No If yes, was It cleaned? ❑ Yes ❑ No
5. Condition of System:
N6 r� <�.
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location-where contents were disposed:
Lowell Waste Water
( t
SignAtuTe qf Hiaul Date
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