HomeMy WebLinkAboutSeptic Pumping Slip - 1353 SALEM STREET 7/2/2018 Commonwealth f Massachusefts
RECEIVEbCitY/Town ofd
System Pumping,Reco
rd 30. ��
Form 4 -R
TOWN WRT MDOVr-
HEALTH
DEP ha'provided this fordo`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 fora,check with your
local Board of Health to determine the forret they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Ct•tt . Informiation,
1, System Location: Le Ri h front of House)Left/Right rear of house, Left,/right side of house, Left
Right side of building, Le /Right front of buildilig, Left/Right rear of building, Under deck
Address ` f 4,
City/T wn State Zip Cade
2. System Owner:
Name*
Address(if different from location)
ci !Town
tY State C i
P
Telephone Plumber �}
7
r.
p�®® fig. �
-
1. Date of Pumpingoats 2. (quantity Pumped:
Gallons
3. T e•of S Stern:
YP Y. Cesspool(s) epfiic Tank E) Tight Tank
Other(describe):
4.. Effluent Tee Filter presents e.� ® No If yes, was it cleaned? es ❑ No,
' S. Condition ofstern: �,�,µ�` � ��. �� `t✓' �.r�`�
amu,
6: System Pumped By:
Neil.Bateson • F5821
Name Vehicle License Plumber
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
Sign a UHtuleVCrate
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