HomeMy WebLinkAboutSeptic Pumping Slip - 1264 SALEM STREET 7/19/2018 Commonwealth of Massachusefts
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AI� AMENT
®EP has provided this form for use-by local Boards 6f Health. Other forms r ay be'ins®d, but the
Information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forth they use.The System Pumping record must be submitted to
the local Board of Heath or other approving authority.
A. lInformation
1. System Location: Left/Right frant of house, Left/Right rear of house, L ht side of hie, Left
Right side of building, Left I Right front of building, Left I Right rear of building, n er
AddressJA A'A
.
City/Town state zip Eade
2. System Owner:
taame'
Address(if different from location)
Cityrrown state 2
Telephone Number
® Pumping�.Rpcord V. ,
1. bate of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ® Cesspool($) alseptic Tank ® Tight Tank t
Other(describe):
4. Effluent Tee Filter present'? El Yes o if yes, was it cleaned? El Yes ® No,
5. Condition of System: ' V\'
6. System Pumped By:
Neil.SatesM ` F621
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Loc. n _here contentsfwere disposed:
CLS: Lowell Waste Water
sign a hthuie • mate
tMrm4.doG-06/03 system Pumping Record Page 1 of 1