HomeMy WebLinkAboutSeptic Pumping Slip - 1187 SALEM STREET 5/1/2017Commonwealth of Massachusetts
City/Town of
yste 'umpif ec rd
Fo 4
RECEIVE:7).
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 Informatio
1. System Location
igh ro t of ho , Left / Right rear of house, Left / right side of house, Left /
Right side of buUdFi, Left / Right ront of building, Left / Right rear of building, Under deck
2. System Owner
Name
Address (if different from location)
City/Town
Stat
Li( Zip Code
Telephone Number
pin
Reco
1. Date of Pumping
3 Type.of system':
EJ Other (describe):
4. Effluent Tee Filter present? 1:3 Yes
Con5 dition of of System.
Date
Cesspool(s)
2. Quantity Pumped: Gallons
ptic Tank 0, Tight Tank
If yes, was it cleaned? D Yes L] No,
: System Pumped By:
Neil. Bateson •
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
a
Sign
Lowell Waste Water
F5821
Vehicle License Number
Date
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