HomeMy WebLinkAboutSeptic Pumping Slip - 518 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: Left/Right front of hous , L Rig a of hou , Left/right side of house, Left/
side of building, Left/Right front of bulLeft/Right rear of building, Under deck
Right 9� 9
Address
Citylrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
CitylTown State � Zip Code
Telephone Number
3 I
B. Pumping Record �.
1. Date of Pumping Date 2. Quantity Pumped: Gallons _y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of System: ���;r I,„ C � � �n •
�I
6. System Pumped By:
Neil.Bate ibn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents-were disposed:
_1
_L S. Lowell Waste Water /
Sign Date
0orm4.doc•06103 System Pumping Record•Page 9 of 1