HomeMy WebLinkAboutMiscellaneous - 1510 SALEM STREET 4/30/2018 (2) 1510 SALEM STREET
210/106.A-0028-0000.0
Commonwealth of Massachusetts
4 City/Town of
System Pumping Record jb�e
Form 4
DEP has provided this form for use by local Boards of Healt . er formbut the
information must be substantially the same as that provided �` a , check with your
local Board of Health to determine the form they use. The St be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of hous Le ig rear of ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left ight rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner: —
Name
Address(if different from location)
Cityrrown Stat
C-5
Telephone Number
B. Pumping Record
l
1�
1. Date of Pumping 2. Quantity Pumped:
p g uan
Date 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. Con ition of Syst�em� LA-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents were disposed:
G.L,S Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03
System Pumping Record•Page 1 of 7
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