HomeMy WebLinkAboutSeptic Pumping Slip - 437 SALEM STREET 5/1/2017Commonwealth of Massachusetts
City/Tow of
yStel P pin ecord
For 4
, )\
DEP has provided this form for use,by local Boards of Health. Other forinS 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 Informatio
1. System Location: Left / Right front of housJtfltfreof house, Left/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2. System Owner:
State
Zip Code
Address (if different from location)
City/Town '
Telephone Number
P
o
g Re o d
1. Date of Pumping
3. Type of system":
El Other (describe):
4. Effluent Tee Filter present? Ei Yes
5. Condition of System:
2. Quantity Pumped:
Date
Cesspool(s)
Gallons
ptic Tank 0 Tight Tank
If yes, was it cleaned? 0 Yes El Na
jA,
6: System Pumped By:
Neil Bates -or!
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign Haule
F5821
Vehicle License Number
Date
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