HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 506 SALEM STREET 11/19/2019 Commonwealth of Massachusetts RECEIVED
City/Town of Nov 19 2019
oovER
System Pumping Record TOM OF NORTH AN
TMF►dT
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 Locationz!Ceft/Right runt of hou es , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rigimt—front of building, Left/Right rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping record
c
1. Date of Pumping Date < < 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ED Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [9 No 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. Location where contents-were disposed:
G L S. Lowell Waste Water
Sin a Haul —
g Date
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