HomeMy WebLinkAboutSeptic Pumping Slip - 1100 SALEM STREET 9/29/2015 Commonwealth of Massachusetts l
= City/Town of .
S stem Pumping-Record
y
Form 4
1
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 Locatio e Rig ront of haus , Left J Right rear of house, Left/right side of house, Left J
Right side of bulling, Left/Right ront of building, Left/Right rear of building, Under deck
Address � __
S ..
City/Town State Zip Code
2. System Owner.
. r
Name'
Address(if different from location)
City/rown ' State Zip Code
t
Telephone Number
3 �
1
e,
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons �T
3. Type-of system: ❑ Cesspool(s) ❑°'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0,146 If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
rq
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location w
-, here contents were disposed:
6
Lowell Waste Water
110A
95griAtu a Haule Date
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