HomeMy WebLinkAboutSeptic Pumping Slip - 1260 SALEM STREET 6/1/2017 Commonwealth MassachusettsRE
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® P has provided this form for use-by local Boards 6f Health. Other forma 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 ystenn Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Facility, Information
1. Dight side of building, Leff/Right front of building,e Left/Right reser of building, Und 6 Wko�s Left I
System g o
cic
Address —
citylrown state Zip Code
2. ,System Owner: �
Name,
Address(if different from location)
City/Town Stater � ...�i`~-,'7 Zip C d
`telephone Number
.B. Pumping Record
1. Fete of Pumping oats 2, Ou6ntity Pumped:
Gallons
. T`ype•of system: El Cesspool( ) Septic Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yep No If yes, was it cleaned? Yes No,
Condition of erste
p,
6., System Pumped 6y:
Nell.Sates-on F5321
Mame Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ti ,n; he contents were disposed:
L
Lowell Waste Water
sl n Hula -Da F
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Morm4.doo-08/03 System Pumping Record w Page 7 of 1