HomeMy WebLinkAbout- Septic Pumping Slip - 1514 SALEM STREET 9/24/2018 Commonwelalthchu
own of
Sy
U I11 �'Record
Farm
DEP has provided this forrni for use-by local Boards of Health. Other forms maybe"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 to
the local Board of{health or other approving authority.
A. Facll#ty In for Mation
1. System Location: Left/Right front of house, Left/Right rear of house, Left l t side of hoes , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under 6k
Address
City/Town state Zip Code
2. System Owner:
• t
Address(if different from location)
Citylrown ' '. state- � � - c
• P
Telephone Number
Pumpingt
1. Date of Pumping Date 2 Chu tity Pumped: Gallons
r
3. Type-of system: Cesspool(s) eptic Tank [ Tight Tank
[] Other(describe):
4. Effluent Tee 'Filter present'? 0 Yes No If yes, was it cleaned? 0- Yes ® No,
5. Condition of System: KIC9
C c
6. System Pumped By:
Neil.Batesim+n F5821
Marne Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo n ere contents-were disposed:
S Lowell Waste Water
•
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t5form4.doc•06/03 System Pumping Record•Page 1 of 1