HomeMy WebLinkAbout- Septic Pumping Slip - 1565 SALEM STREET 6/13/2019 III
ii
I
i
Uty/Town of
System Pump*ng Record
Form 4
ry
Commonwealth o,f Massachusetts
DEP has provided this for for oo local'Boards r ° ' . " ��� "�: f° but:the
Information-must be l i r . Before using Ahis Healthlocil Board of determine . � The.System Pumping t
the local Board of Health or other approving authoAty.,A. Facility InforMation
1. System Location.- Left/Right front of house, Left/Right rear of.house, . right sidehouse, Leftt
Ri'ght side of buillding, Left, Right fr6nt of building, Left,/Right rear cif building, Under deck
Address ir
IWIC
Site Zip Cede
2'. System Owner,
Add' 1
rs different from location)
City,frownin
CY, T."s
Telephone Number
B. Pumping K-ecord
1, Date of Purnping
ul
Date Gallons
3. Type-of� system1b. C1po-sepric�Tank Ell Tight Tank
Other(describe).-
4. Effluent Tee Filter present? O� Yes 0 If yes, was,it cleaned? Yes 0 N
. Condifion
�6 System Pumped By.-,
l atesbg F58,21
Name Vehicle License Number
Bateson Ehte rises Inc`
Company
contents-wereT Location where
Lowell Waste Water
Sign Date
t .dw Pumping r