HomeMy WebLinkAboutSeptic Pumping Slip - 1432 SALEM STREET 6/6/2018 Commonwe8ifth of Massachusetts
JUN 0 4 .201b
City/Town of n0v�
14 Or
SY,4tem Pumping- r
Form 4
DEP has provided this form'for use-by local Boards of Health. Other forms may be'used,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 forrh they use.The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority,
A. Facloty, InforMation
1. System Location: Left/ t front t of Nous , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rightof buildlnig, Left/Right rear of building, Under deck
Address 1
Cityfrown State Zip Code
2. System Owner:
Marne'
Address(if different from location)
cityrrown ' Stat Zip Code
E 'telephone Number
Pumping r
1, bate of Pumpingbate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ® Yes ❑ No,
6. Condition of System: r^
6. System Pumped By:
Nell.Satesart F6821
Name Vehicle license Number
_Bateson Enterprises Inc-
Company
7. Location w eco contents-were disposed:
L S: Lowell Waste Water
Sign a Haule bate
15form4.doc-06103 System Pumping Record Page I of 1