HomeMy WebLinkAboutSeptic Pumping Slip - 10 CAMPBELL ROAD 6/15/2017 Commonwealth of Massachusetts
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System Pumping.Record 0
Form 4
DEP has provided this form far use-by local Boards of*Heaith. Other forms may'be'used, but the
information,must be substantially the same as that provided here. Before using.this form, "
heck with your
local Board.of Health to determine the forfn they use. The System_ Pumping Record must be submitted to
the local.Board of Health or other approving authority. 3
A. Faci ty Information
I. System Location: Left/Right front of house, Left i Right rear of house,oeff. gh s„• a of housO,, Left f
Right side of building, Left/Right front of building, Left/Right rear cif blJnder��ck
Address
Citylrown State Zip Code f
2, System Owner:
Name,
J
t
Address(if different from location)
I
CitylTown State. C `ryip co w
Telephone Number
. r
B.
Pumping Record ,
9. ®ate of PumpingDate Z Quantity Pumped: 400
Gallons
3. Type-of system: ❑ Cesspool(s) 0 e�ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes C] No,
5. Condition of System: /
r
6: System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Ehterer€ses Inc
Company
7. Loca 'o�vher contents were disposed:
GLS: Lowell Waste Water
sign a Haute Date
MormCom-06/03 System Pumping Record•page 1 of 1