HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 492 SALEM STREET 7/31/2020 Commonwealth of Massachusetts77
City/Town of
System Pumping Record JUL 312020
�. Form 4 ,�1L.
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 eft P Rig ront of house, Left/Right rear of house, Left/right side of house, Left
Right side of buil id ng, Left/Rig ront of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Zip Cade
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 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
4S�ignkjufe cfHaijiul Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1