HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1276 SALEM STREET 11/4/2019 .&\- 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 foram,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,4A/_RighQear of house eft/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
i ��(- — l s1 <4
citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CWTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping gate n S uantity Pumped: I �'
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: N)L
f
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatie"here contentewere disposed:
L S Lowell Waste Water
Sign We cfHauWUpate
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