HomeMy WebLinkAbout- Septic Pumping Slip - 1276 SALEM STREET 10/19/2018 RECEIVED
-C Commonwealth of Massachusetts
f 0M 19 20111
City/Town o
'FOWN OF WRTH MWM
System Pumplang Record
tJE-ALTH DEPARTMW
Fonn 4
DEP has provided this form for use�by local Boards of Health. Other forms may be'used, b'ut 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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Factlity Inform' sItIon
1. System Location: Left/Right front of house,(Gb/RIghT@jr of_houseLeft/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear(if building, Under dock
Address
Zip Code
Cityrrown at.
2. System Owner:
Name'
Address(if different from location)
cityrrown stater Zip Code
Telephone Number
,13. Pumpfn-j--Record -- to -
9. Date of Pumping Date u6nfily Pumped: Gallons
3. Type-of system: El Cesspool(s) Septic Tank Tight Tank
E] Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? E] Yes No
5. Condition of System,
6. System Pumped By:
Nell.6ates7og ,-, F6821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
Lowell Waste Water
L
Sign a Heine bate
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