HomeMy WebLinkAboutSeptic Pumping Slip - 1510 SALEM STREET 12/9/2017 : Commonwealth of Massachusetts
UtKown of .
System Pumping.Record
Form 4
DEP has provided this fort'for use}by local Boards of Health. Other forms may used, but the
information-must be substantially the same as that provided here. Before using-fhis 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. Information-
1. System Location: Left!Right front of Hous a aro. esu . eft/right side of house, Left I
Right side of building, Left 1 Right front of bu I of building, Under deck
Address
ria
Cityrrown State Zip Code
Z System Owner:
L
Name'
Address(if different from location)
Cityrrown Stater Zip Code
Telephone Number
t
.B. Pumping tZecord
1. Date of Pumping pate /Septic
Quantity Pumped:
Gallons
ype-of
3. T s y,stem:
El - Tank ® Tight 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:
Neil.Bateson - F5821
Name Vehicle License Number
-Bateson Enterprises Inc,
Company
7. Locatio re contents-were disposed:
G L S: Lowell Waste Water
/7
SignAftfe 9t HulerU Date
MbrmCdov 06103 System Pumping Record Page i of 1 G
is