HomeMy WebLinkAboutSeptic Pumping Slip - 1907 SALEM STREET 9/24/2015 ornrx�onwe lth of Massachusetts
City/Town of
System Pumping,Record
Form 4
DEP has provided this farm 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/ igbt r othousel, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Addressn,_ a __ 0C ,...,
City/Town State Zip pie ,��,„ V
2. System Owner.
y SEl" t! 2015
Name' . 8 OW�0f 11, , t l i l
Address(if different from location)
Citylrown State ip Coe
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Telephone Number
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B. Pumping JRecord .. �.
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? ❑ No If yes, was it cleaned? F1_Yes--[]_No,
5. Condition of Systerry
..
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
Sign a 9t Haule Date
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