HomeMy WebLinkAboutSeptic Pumping Slip - 459 SALEM STREET 6/6/2018 /Commonwealth of Ma s chuseft Cjt� JUN qp dgyg
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System Pumping,Record
u' Form 4
DEP has provided this form-for use-by local Boards 'of Health. Other farms may b used,but the
information-must be substantially the Larne as that provided item. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be subrnitted to
the local Board of Health or other approving authority.
A. Facipty, Information .
1. System Location:( /Rlght rata of hou eft/Right rear of house, Left/right side of house, Left
Right side of buiCdi"rig, Left/Right ron -6Tb ildirtg, reit/Right rear of building, Under deck
Address L ell �., a'.� t ai .
citytTown -- - State Zip Code
2. System Owner:
Piame'
Address Of different from location)
Cityrrown State- Zip Cade
•
• p __ __ rA �,..,� � � ,�._ .may
'telephone Plumber
13. Pumping Record
1. bate of Pumping Datentlty Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes ® No If yes, was it cleaned? 0/yes Cl No
5. Condition of System: 6x,�,
6. System Pumped By:
Nell.Bateson F6821
Name Vehicle License Plumber
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
rL~ Lowell Waste Water
Sign a Fisule Cate
tMrm4.doc-06103 System Pumping Record®Page 1 of 1