HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 CAMPBELL ROAD 6/7/2021 Commonwealth of Massachusetts RvCEIVED
City/Town of
System Pumping Record oFNCR1HANDOvER
Form 4 100p�TN pEPARTMSW
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: Left/FU t front of house,'Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fro—n�of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State � —Z ip Code _
ft�
Telephone Number
B. Pumping Record
J)- t
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 LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Pei
d_�C& how� It
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio contents were disposed:
G L S Lowell Waste Water
Signitute cf Haul Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
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