Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 CAMPBELL ROAD 8/4/2021 : Commonwealth of Massachusetts RECEIVED City/Town of AUG U 4 2021 System Pumping Record TO, OFNORTHANDO� Form 4 HEALTH DEPARTMENT 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 focal 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/ igh front o Left/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 Address ` � ( iI, Citylrown U State r`J Zip Code 2. System Owner. Name Address(if different from location) City/Town ��s / Z;a Telephone Number U B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©-wo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: I c�L_ x�CJ 0 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio here contents were disposed: .L Lowell Waste Water 4&ignAtOe Haul Date t5f6rm4.doc-06/03 System Pumping Record•Page 1 of 1