HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 437 SALEM STREET 11/26/2019 RECE�vE�
Commonwealth of Massachusetts Nov 26 20�g
City/Town of4 Of H AN��E�
System Pumping Record SON6�Hp PPR'tMEN1
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 houseAi t rear of hou , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Lf
cftyRom State Zip Code
2. System Owner.
lam-CGS-�-�
Name'
Address(if different from location)
Telephone Number
B. Pumping Record Ic
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly'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. Lo contents-were disposed: ,
G L S. Lowell Waste Water
Sign a Haul
Date
tftrm4.doc-06/03 System Pumping Record•Page 1 of 1