HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 CAMPBELL ROAD 11/4/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/Right rear of house ( /rig sidd of housei Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Underdeck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown gee ip e
Telephone Number
B. Pumping Record p
1. Date of Pumping pate 2. Quantity Pumped-
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
�-UA'_r_'dC �
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locabefhwhere contents-were disposed:
.L S. Lowell Waste Water
Sign a Haul
p
t5form4.doca 06/03 System Pumping Record•Page 1 of 1
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