HomeMy WebLinkAboutSeptic Pumping Slip - 1440 SALEM STREET 1/17/2017Commonwealth of Massach
City/Town of
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HEALTH Dt.reut NerNi
DEP has provided this form. for usell 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 !rotor n
1. System Location: Left / Right front of house, Left Jg1it rarbffio 40 Left/ right side of house, Left /
Right side of building, Left / Right frOnt of building, Left / RighffeWcif building, Under deck
Zip Code
2. System Owner.
Address (if different from location)
City/Town '
State
Tel phone Nu ber
Zip Code
PLJI pi g
ec
1. Date of Pumping
Type of system':
El Other (describe):
4. Effluent Tee Filter present?
It
' 5. Condition of System:
6. System Pumped By:
Neil Bates-or,i
' Name
Bateson Enterprises Inc.
(I) t'e' 2.Quantity Pumped:
Date Gallons
Cesspool(s) Septic Tank El Tight Tank
Yes Ei No
Company
7. Loca pyvhsre contents were disposed:
L S.
Sign
Lowell Waste Water
If yes, was it cleaned? Yes ID No,
C [-Ce',vvraL. ')AC ACCvv14-1
F5821
Vehicle Lcanse Number
Date
Worn-14.de°. OS/03 System Pumping Record Page 1 of 1