HomeMy WebLinkAboutSeptic Pumping Slip - 542 SALEM STREET 5/22/2018 Commonwel8ifthcu RECEIVED
City/Town of 2 2018
SyMem Pumping.Record
Form.
DEP has provided this fiorrri for use-by local Boards of Health. Other forms may "used,but the
information roust be substantially the same as that provided here. Before using.this fora:,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. cry . InforMation
1. System Location: Left/Right front of Mouse Left I h
y g rear of hoes �Left-/right side of house, Left
Right side of building, Leff/Right front of building, ire g " rear of
building, Under deck
Address
cz
L- Ale I Fc_��XJ,
Cityfrown State zip Code
2. System Owner: .",
Name'
Address(if different from location)
r
citylrown State- Zip Code
r Telephone Number
f
Pumping 1Record
1. pate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) 0-Septic Tank (l Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? ElYes ® No,
5. Condition of System: p
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
S Lowell Waste Water
f
Sign Hbui Date
t5form4.doc-08103 System Pumping Record^page 1 of 1