HomeMy WebLinkAbout- Septic Pumping Slip - 1907 SALEM STREET 9/24/2018 o m [t of Massachusetts
w i f Pumping..
Fonn 4
DEP has provided this form for use-by local Boards of-Health. Other forms may be'used,brut the
information must be substantially the tame as that.provided hare. Before using.this form,check with your
local Board of Health to determine the forrrr they use.The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facloty. InforMation
I. System Location: Left/Right front of house, Left I Right rear of house, Left./right side of house, Left
Right side of building, Leff/Fight front of building, Left/Right rear of building, Under deck
. Address
citylrown State Zip Code
2. System Owner:
JA
Flame`
Address(if different from location)
Citylrc►wn ` State C L Zip Coda
— T 9
Telephone Number
9. Date of Pumping (quantity Pumped: Gallons
Date
3. Type-of system: [l cesspool(s) eptc Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present`? es ® No If yes,was it cleaned? No,
a. Condition of System,
6: System Pumped 6y:
Neil.Bate son F6821
Name Vehicle!_icense Plumber
Bateson Enterprises Inc-
Company
7. Lo ti ere contents-were disposed:
. S Lowell Waste Water
F
Sign a Hhul � � Date -
15fbrm4.doca 06/03 System Pumping Record d page 1 of 1