HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1550 SALEM STREET 11/19/2020 .S-\ Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
NOV 19 2020
Form 4
r' TOWN nc ninpTy MDOVER
DER has provided this form for use=by local Boards of Health. Other forms maybe used,61 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: Le ight�ron
eft 1 Right rear of house, Left I right side of house, Left
Right side of building, Left/Rldirig, Left/Right rear of building, Under deck
Address C�-
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stat
1 --
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Sateson Enterprises Inc-
Company
7. Location where contents-were disposed:
�_L S Lowell Waste Water
� —
Sign a Haul Date
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