HomeMy WebLinkAboutSeptic Pumping Slip - 151 SALEM STREET 10/26/2015 •
Commonwealth of Massachusetts
i v
City/Town of 1
System Pumping-Record
Form
4
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
1
the local Board of Health or other approving authority.
A. Facility.information
1. System Location: Left/Right front of house eft'jAigh Left/right side of house, Left/
Right side of building, Left/Right front of bui Ing, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner. 7
Name'
Address(if different from location)
cityfrown ' State ,�p Code ;
Telephone Number t ,
a
ping Record
B. Pum w. .
1. Date of Pumping Date 2. Quanti ty Pumped: Gallons ,--T
3. Type-of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J'No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
RE""'IVED
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number M.)OVER
Bateson Enterprises Inc MEN'T
Company
7. Location-where contents were disposed:
LS'..M Lowell Waste Water
_§ig_n_Vtu a Haute Date
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