HomeMy WebLinkAbout- Septic Pumping Slip - 518 SALEM STREET 1/8/2019 Commonwealth f Massachusetts
a City/Town of
System n.
Pumping
Form
DEP has provided this form for use-by local Boards of Health. Other forms may'be'used, but the
information-roust 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 Infor Mation
1. System Location: Left/Right front of hious /Rig rea htou � Left/right side pf house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � C Cr.✓ �,� ��h�....- `' ���``lw.,"" _��.,,o�..`�'
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
CitylTown State
Telephone Number
m Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) eptlk Tight Tank
Other(describe):
4. Effluent Tee Filter present.? ® Yes o If yes, was it cleaned? E Yes El No
5. condition of stern:
. System Pumped By:
Nell Bateson F5821
Flame Vehicle License Number
_Sa!eson Enterprises Inc
Company
7. LocanL.S%r0
ere contents-were disposed:
G Lowell Waste Water
Sign a Hhui Gate
t5form4.doc-06/03 System pumping Record page 1 of 1