HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1550 SALEM STREET 11/4/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for us&by local Boards of Health. Other forms may *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 ght front of hour Left I Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of buildirg, Left/Right rear of building, Under deck
Address
c
�'r o" Zip Code
2. System Owner.
Name' C---�
Address(9 different from location)
cwrown (Z Code
Telephone Number
6. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): /
4. Effluent Tee Filter present? ❑ �Yes ❑ O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 1 b
Z_.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents,were disposed:
G L S: Lowell Waste Water
Sign a haul Date
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