HomeMy WebLinkAboutSeptic Pumping Slip - 506 SALEM STREET 11/16/2016 Commonwealth of Massachusetts
City/Town of . RECEIVED
System Pumping.Record NUV 18 '1016
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may a 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 Informiation
1. System Location: Left/ , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Le rht1!wq_ntofhou
Rht ron of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
cityfrown " State ZID Code
Telephone Number
.B. Pumping Record
[t- 6 ,1
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ' eptic Tank ❑ Tight Tank t.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [Data f If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
Kb
6. System Pumped By:
Nell.Bates ri ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
Lowell Waste Water
Sign a Haule Date
t5form4.doc•08/03 System Pumping Record•Page 9 of 1