HomeMy WebLinkAbout- Septic Pumping Slip - 1550 SALEM STREET 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumpling Record
Form 4
�'4? .`C1,°
�i 4 Ua
DEP has provided this form for use-by local Boards of Health. Other forms may be bled,but the
information-must be substantially the same as that provided Mere. 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. Factlity InforMation
9. System Location: L fight frcr�t use eft/Right rear of house, Left./right side of house, Left
Flight side of building, Ig t front of building, Left/Right rear of building, Under deck.
Address
Citylrown Mate Zip Code
2. System Owner
Name
Address(if different from location)
Cityrrawn State �� p arda
__ G--cam �
Telephone Number
Pumping
1. Gate of Pumping Date 2. Quantity Pumped:
Gallons
3. TypeWsystem: Cesspool(s) eptic Tank D Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? ® Yes ® No
5. Condition of System: p
6. System Pumped°.By:
Neil.Bateson F5821
Name Vehicle Ltcense Number
_Batpson Enterprises Inc
Company
7. Location ere contents-were disposed:
4 S: Lowell Waste Water
Sign a Haute Cate
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