HomeMy WebLinkAboutSeptic Pumping Slip - 1440 SALEM STREET 1/12/2016 I
• 1
Commonwealth of Massachusetts �
= City/Town of .
y* tem Pumping,Record
r` Form 4
DEP has provided this form for usezby 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, Left fight rear of housO, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City[Town State Zip.Code,
2. System Owner:
/ ���C ;•
Name'
Address(if different from location)
citylrown State- Zi Code
Telephone Number !
B. Pumping JRecord �.
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 ❑ No If yes, was it cleaned? es ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati are contents were disposed:
ISigne AHaule Lowell Waste Water
Date
t5form4.doe•06/03 System Pumping Record•Page 1 of 1