HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1265 SALEM STREET 9/20/2019 :�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record SEP 2 0 2019
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 here. 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. Facility Information
1. System Location: Left/Right front of house, Left I Right rear of house, L ide of houss, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address `� r"[
L
Citylrown state Zip Code
2. System Owner. P
Name'
Address(if different from location)
mown � `�{� 23P?
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) QSq lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' e contents-were disposed:
G.L.S Lowell Waste Water
�v AA. 4
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151brmCdoa 06/03 System Pumping Record•Page 1 of 1