HomeMy WebLinkAboutSeptic Pumping Slip - 507 SALEM STREET 8/21/2015 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
DEP has provided this form'for usezby local Boards of Health. Other forms may be'used, but the
information-must be substantially the tame as that provided here. Before using.this form., check with your
loca'I Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
(:ie Igfk i n t of - u e, Left/Right rear of house, Left/right side of house, Left I
ystem Locatio jr I. S ' O _�hto�f
Right side of bui g, Left Right front of building, Left/Right rear of building, Under deck
Address 1A
cilyfrown State Zip Code
2. System Owner:
Name*
Address(if different from location)
Cityrrown - State 679 zq e
Telephone Number
B. Pumping Rpcord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of system.* ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yep ff No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys
6.. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. LoZcatfii"hhere contents were disposed:
LLS'.Q Lowell Waste Water
4MOA
-gignAhfo 9t Haule Date
0=4.doc•06/03 System Pumping Record•Page 1 of 1