HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SALEM STREET 10/16/2019 AN Commonwealth of Massachusetts
City/Town of
System Pumping 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 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/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right n6ar of building, Under deck
Address
111
City/Town State Zip Code
2. System Owner: ,
Name
Address(if different from location)
City/Town State� � „Zip Code
Telephone Number
B. Pumping Record
scc,
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) a-S-eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of s m J ^� (� n �; (� , < P
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca'eri where contents were disposed:
Lowell Waste Water
;SigZnAtUfeHaul Date
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