HomeMy WebLinkAboutSeptic Pumping Slip - 1550 SALEM STREET 12/4/2017 Commonwealth of Massachusetts REGEIED
VIwo
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S'iyrt"tetl"1 PLII'17p►tl'1g-Record �� � �� li��,���.��
Form 4 .
®EP has provided this farm fpr use-by local Boards of Health. Other forms may be bsed, 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. Facflifiy. Information .
1. System Location: l=eft 1 1 ht front shouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown state - Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State Zi de
Telephone Number
r
_ t`
. Pumping JRq cord
1. Gate of PumpingDate 2. G2uanti[y Pumped:
Gallons ;��"
3. Type•of system: El Cesspool(s) e- tic Tank ® Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? ® Yes o 1f yes,was it cleaned? [j Yes ® No,
5. Condition of System: / a
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locations her conteints•were disposed:
ISIgn
AHaule
Lowell Waste Water
f
F
Date
0orm4.doc-06/03 System Pumping Record•Page 1 of 1