HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1565 SALEM STREET 7/1/2020 : Commonwealth of Massachusetts RECEIVED
MEMO ENEM City/Town of JUL 0 12020
System Pumping Record
Form 4 TO OF
ER EAL H DEPARTMENT H
DEP has provided this form for use-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/Right front of house, Left ht r r of house eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �C/ ^ � - C�
City/Town (� state Zip Code
2. System Owner.
Name'
Address(d different from location)
City/Town Stater ,� �� !CZip-Code
Telephone Number
B. 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 a_40 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle L►cense Number
Bateson Enterprises Inc
Company
7. Location_,�7 contenter were disposed:
L S Lowell Waste Water
Signitufe cfH1kulWDate
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