HomeMy WebLinkAboutSeptic Pumping Slip - 1276 SALEM STREET 12/17/2015 I
Commonwealth of Massachusetts
City/Town of
•
Sy* t e m Pumping,Re �
r
Form 4 TOWN,
�,��,
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 house(IL /RightT6ar of house,Iteft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig�it rear of building, Under deck
Address
Cityfrown state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown ' State Zip Code
" 0 5 , .. � .
Telephone Number `w
.B. Pumping Rpeord
1. Date of Pumping 5, 2. Quantity Pumped:
Date Gallons ,
3. T e•of s stem:
yp y. ❑ Cesspool(s) � Septic Tank ❑ Tight Tank
❑ Other(describe): ,
4. Effluent Tee Filter present? ❑ Y.s No If yes, was it cleaned? E3 Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locg#on- re contents were disposed:
G L S'.wh Lowell Waste Water
r- a._. ....r .5
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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