HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 150 SALEM STREET 6/7/2021 REC
Commonwealth of Massachusetts EM
071
_ . City/Town of JUN o -7 2
System Pumping Record YQWNOF [)FPPR MEEK*
Form 4 HEALTH DEPARTP�ENT
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(kight rear of house;'Left/right side of house, Left/
Right side of building, Left/Right front of building,Left]Right rear of building, Under deck
Address t S 2 1 j A�`
Cityrrown ( ( State Zip Code
2. System Owner.
Name
Address(d different from location)
City/Town S�� � �,�^l Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U'-�O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: _�
6. System Pumped By:
Neil.Batesnn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo77—
o , s contents-were disposed:
L S Lowell Waste Water
Signitute 9t HtulwU Date
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