HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1476 SALEM STREET 8/4/2021 Commonweaith of Massachusetts RECEIVED
City/Town of AUG 0 4 ZOV
ulSystem Pumping Record TOMEp�V[)EPAR MENT R
Form 4
DEP has provided this form for us&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 Eof
1. System Location: Left/Right front of douse, Lef�Rig
/right side of house, Leftt
R' �e of bul7�g, L /Right front of building, Left/R Under deck
cityiTown State Zip Code
2. System Owner:
Nam
Address(if different from location)
CWTown State Code
?tl
Telephone Number
13. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) bapbe Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y 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. LocatiorLwhere contents-were disposed:
�L S ) Lowell Waste Water
f Y f O- A `)-22 21
Sign a qF Haulev Date
MbnnCdoa 06/03 System Pumping Record•Page 1 of 1