HomeMy WebLinkAboutSeptic Pumping Slip - 506 SALEM STREET 11/10/2015 _ Commonwealth of Massachusetts
City/Town of
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
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location e i t f ont of how , Left/Right rear of house, Left/right side of house, Left/
Right side of buil mg, Left/ ig ron of building, Left/Right rear of building, Under deck
9
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
State-
Telephone/1 Z�►p,Code ;
CitylTown '
Number
K ;
B. Pumping ,Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No;
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
1
7. Locatio a contents were disposed:
qSign L S'. Lowell Waste Water )
/d -� �
-t
a Haule Date
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