HomeMy WebLinkAboutSeptic Pumping Slip - 221 CAMPBELL ROAD 8/11/2016 RECEIVED
-jL Commonwealth of Massachusetts
City/Town of
M
N.
° System Pumping-Record ° u� on°imp `I °c°
Form 4
b• •
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: Le Rig front of house;Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ron of building, Left/Right rear of building, Under deck
Address
City/Town Z State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zi .Code
Telephone Number
.B. Pumping Record �..,
1. Date of Pumping oats 2. Quantity Pumped:
Lallans
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ Ala If yes, was it cleaned? ❑ Yes ❑ Na
S. Condition of System: p i
6. System Pumped By:
Nell Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7, Locatio.."where contents-were disposed:
G S: Lowell Waste Water
Sign a Haule Date
t5form4.doc 06/03 System Pumping Record•Page 9 of 1