HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 518 SALEM STREET 10/12/2021 : Commonwealth of Massachusetts RECelveo
City/Town of pC� j o,?.W
System Pumping Record TNANDOVER
FOriln 4 TC NN Ep,1.TH DEpp,RTMT
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,ref'f0JgttAjar 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 Q � &��`4-tA-
Citylrown State Zip Code
2. System Owner.
Name.
Address`d different from location)
Cityfrown Staff L_ � � e
Telephone Number
.B. Pumping kecord
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type�of system: ❑ Cesspool(s) (3- eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes ❑ No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
c� 1.
6. System Pumped By: �p�
.-N`- � e -`ram-' F5821
Name Vehicle License Number
Bateson Enterprises Inc 1
Company
7. Locations where contents-were disposed:
L S. Lowell W te, ater
L
Sign a Heulet Date
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