HomeMy WebLinkAbout- Septic Pumping Slip - 437 SALEM STREET 11/26/2018 .�L Commonwealth of Massachusetts RECEIVED
City/Town of
NOV 2
System Pumping Record
Fonn 4 f0*1 C')F NORI+�pjqj,)0VER
�EAI.l i�I')EFIARWENT
®BP has provided this form for use-by local Boards of Health. Other forms maybe`used, 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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Algh1!5:;r;o:f:h7oNsi, Left./right side of house, Left I
c,
Right side of building, Left/Right front of buirnq, Left/ ig re,ar of building, Under de'ok
Address
Lj
City/Town State zip doFe,
2'. System Owner
Name'
Address(if different from location)
City/Town Stater 1p�?dq
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2. Quiin ,Pumped: Gallons
3. Type-of system: E] Cesspool(s) 9--Sepfic Tank E3 Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? ® Yes - o If yes, was it cleaned? Yes E] No
5. Condition of System:
6. System Pumped By:
Nell.Bat esion F5821
Name Vehicle License Number
Bateson Ehte!prises Inc
.....................
Company
7. jLoon here�contents-were disposed:
ac's.. Lowell Waste Water
Sign e Houl Date
l5fbrm4.dac-06/03 System Pumping Record•Page 9 of 1