HomeMy WebLinkAbout- Septic Pumping Slip - 221 CAMPBELL ROAD 1/7/2019 Commonwealth u N '
City/Town of
System Pumping Record
" Form 4 tIO
DEP has provided this form for use4by local Boards of Health. Other forms maybe used,but the
information-roust be substantially the tame 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.
Ficility Informiation
1. System Location: Lela Iaht root of ha eft/Right rear of house, Left/right side of house, Left!
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Cityy/rown State Zip Code
2'. System Owner
Name'
Address Of different from location)
CitylTown Stat� �p Code
Telephone Number
Pumping Rec1°
1. ®ate of Pumping Date 2. Quontity Pumped:
Gallons
3. Type-of system: Cesspool($) al
eptic Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? [] Yes if yes, was it cleaned? ® Yes El No
5. Condition of System: OC
6. system Pumped By:
Nell.Batesan F6821
Name Vehicle License Number
_Bateson Enterprises Ina
Company
7. Lo ontenfis,Were disposed:
G Lowell Waste Water
Sign a Hhul Date
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