HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1260 SALEM STREET 5/26/2020 Commonwealth of Massachusetts RECEIVED
City/Town of MAY 2 6 2020
System Pumping Record TOWN OFWWHMW
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Form 4 HEALTH I)EPJ�TAIL
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 Location: Left/Right front of house, Left/Right rear of house, Left i ht side of house Left
Right side of building, Left/Right front of building, Left/Right rear of building, lJn er tr
Address
C'rty/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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:
Lowell Waste Water
Sign a Naul Date CJ`
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