HomeMy WebLinkAboutSeptic Pumping Slip - 437 SALEM STREET 4/24/2018 Commonwealth
N
itY own of A PR 2 4 2 01 t�l
SY,4tem Pumping.Record 111 Nll�')MLR
Form 4
®EP has provided this form for use-by local Boards of Health. Other forms may be'used,brat 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 forn7 they use.The System Pumping Record must be submitted f®
the local Board of Health or other approving suthorlty.
A. Facility Infor Mation
1. System Location: LeI/Right front of douse, Right r a t o�c�s , Left/right side of house, Left
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
Address
City/rown state Zip Code
2. System Owner:
• • Name'
!Address of different from location)
Cityfrown ' State
'telephone Number `
i
® PumpingR-9cord
I. bate of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ® Yes ❑ No,
5. Condition of System* /A
6. System Pumped By:
Neil.Batessbn F5821
Name Vehicle Llcense Number
Bateson Enterprises ises Incr
Company
7. Lo ti ire contents-were disposed:
X. G L Lowell Waste Water
. F
Sign a Maul Date
f5forrn4.doc-06/03 System Pumping Record Page 1 of 1