HomeMy WebLinkAbout- Septic Pumping Slip - 506 SALEM STREET 1/8/2019 Commonwealth of Massachusetts
City/Town of
Jr
System
R y
'Pump'ng Record
Form 4
DEP has provided this form for use>by local Boards of-Health. Other forms may be'used,but the
information-must be substantially the same as that provided hare. Before using.this form,Check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Facility Infor Mation
1. System Locabo .P', Left
lg front thh;o;,us:2,
Left/Right rear of house, Left/right side of house, Left 1
Right side of bui / lding, Left/Right rear of building, Under deck
Address s
Owner
/ Mate Zip Code
2. System
Name
Address(if different from location)
Cityrrown state
Telephone Number
Pumping r
1. ®ate of Pumping rate 2. Quantity Pumped: Cations
3. Type-of system: [] Cesspool(s) Septic Tank Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? 0 Yes o If yes, was it cleaned? Yes ® No
6. Condition of Sy to .:
v- /\A� \ 0"
6, System Pumped By:
Neil.Bateson I"5821
Name Vehicle License Number
Sateson Enterprises Ina
Company
7. Locatio h e contents-were disposed:
C L Lowell Waste Water
aA Bz6z�;
Sign 1 iwl gate
15form4.doeb 06/03 system lumping Record.page 1 of 1