HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1432 SALEM STREET 5/18/2020 PZZENED
: Commonwealth of Massachusetts
_ City/Town of + Z026
System Pumping Record -T AW0YM
Form 4 WALTH M;�Wj,° T
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 farm 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 rear of building, Under deck
Address 14
j d �- , '^�`-
Ctty/rown - State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Z^Code
Telephone Number of
B. Pumping Record
E t
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-8Lp Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: /J ' �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
G L S. r Lowell Waste Water
Sign a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1