HomeMy WebLinkAbout- Septic Pumping Slip - 1116 SALEM STREET 1/8/2019 [i f i p
Commonwealth of Massachusetts
CityfTown of
K. ya Systemping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information-trust 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 ward of Health or other approving authority.
A. Facift Information
1. System Location: Loft/Right front of hous , Left Ig r�heft-/right side of house, LeftRight side of building, Left/Right front of b " ng, Left/ lding, Under deck
Address �1, � �✓ �..� � �,,.,
Cityfrown ,Stets Zip Cone
2. System Owner:
Name'
Address Of different front location)
cityrrown stater Zip Code
Telephone Number
® Pumpling K-ecord
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type�of system: El Cesspool($) epfic Tank E] Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes p o If yes, was it cleaned? E Yes ® No
5. Condition of System:.,t
. System Bumped By:
Nell.Batesan F5821
Name Vehicle License Number
Bateson tr� t�rises Inc-
Company
7. �TG, elsj?
re contents-were disposed:
Lowell Waste Water
`f MOA
signAtute f Haul Crate
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