HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1440 SALEM STREET 1/14/2021 :�L\ Commonwealth of Massachusetts RECEIVE®
NNE City/Town of
System Pumping Record JAN 1 2021
Form 4
,IT
DEP has provided this form for us&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 K lgh rear of hows.4 Left/right side of house, Left
Right side of building, Left/Right front front of building, Le ig rear of building, Under deck
Address r t (CJ sLf
Citylrown �l `( state Zip Code
2. System Owner.
Name
' !:42
Address(if different from location)
City/Town
Telephone Number
B. Pumping record
t D--
1. Date of Pumping Date 2. Quantity Pumped: moons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? es No
5. Condition of Syst :
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. LocationAmbere contents-were disposed:
AeHaui��
Lowell Waste Water
0. [C-)-
SigWUDate
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