HomeMy WebLinkAboutSeptic Pumping Slip - 1440 SALEM STREET 12/26/2017 Corn onwealth of Massachusetts
RECEIVED
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Y.4. t+em Pumping-Record
Form 4
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DEP has provided this form`for useaby local Boards of�Health. Other forms maybe 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.
t
A. Facility InforMation
1. System Location: Left/Right front of house, Left d i I Left/right side of house, Left/
Right side of building, Left/Right front of building, Left l Right rear of building, Under deck
Address
(fUA �
city/rown State Zip Code
2. System Owner,
Name'
Address(if different from location) j
Cityrrown ' State- Zip Code
Telephone Number
. Pumping Record
?. Gate of Pumping Sb
Date 2 uantity Pumped: ------- (`
Gallons - --
3. Type-of system': Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? Yes E] No If yes, was it cleaned? /Yes ❑ No.
6. Condition of System:
L 4 jj
6: System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio where contents-were disposed:
CLS'. Lowell Waste Water
aA
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Sign a_fH_i3uleV Cate f
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