HomeMy WebLinkAboutSeptic Pumping Slip - 1116 SALEM STREET 10/25/2017 Commonwealth of Massachusetts RECEIVED
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C4/Town ofOCT '�'`a " 011
System Pumpl n -Record
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Form 4 T OF�iO P�A .
tjEALTH DEPARTMENT
DEP has Provided this form`for use=by local Boards of Health.Other forms maybe*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. Informi ation
1. System location: Left/Right front of Mous ,&r1hga.,
Righ r ar of houspl Left/right side of house, Left/
Right side of building, Left/Right front of buileft 1 ig rear cif building, Under deck
Address
City/rown state zip Cone
2. System Owner.
Name,
Address(if different from location)
City/Town stag zip Code
F
Telephone Number `
.B. Pumping Rpcord
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. T e•of s stem: '
Type-of Y, ❑ Cesspoo!(s) Septic Tank El Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes No If yes, was it cleaned? ❑ Yes ® No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location phe a contents-were disposed:
.L S: Lowell Waste Water
.-7
signku a Houle hate F
0=4.doca 06103 system Pumping Record•Page 9 of 1