HomeMy WebLinkAboutSeptic Pumping Slip - 1116 SALEM STREET 12/17/2015 1
Commonwealth of Massachusetts
City/Town of
Sy teen Pumping-Record
Form 4 u!!�iivaut°
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 hour wplhga.,Rig t fear of house k Left/right side of house, Left/
Right side of building, Left/Right front of bul Left/Right rear of building, Under deck
Address °
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown ' State Zip Code
..„ I '-1 l
r'4.
Tele an um er
3 �
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank 1.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste :
a
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S Lowell Waste Water
o f
Ww.
Sign a Haule Date F
t5form4.docr 06/03 System Pumping Record•Page 1 of 1