HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 328 CAMPBELL ROAD 7/18/2022 Commonwealth of Massachusetts
City/Town of I)Dfty-\
System Pumping Record
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
P information must be substantially the same as that provided here. Before using this form, check with your
�O '�C athelocal Board Health
of Healltth ordetermine
other approving ng they
authority within 14 day from Pumping
tthe pumping date submitted to
e in
��oP�Q accordance with 310 CMR 15.351. -
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, l
use only the tab 3d 0(cv)j_p L�l--t`l' - ------------ ——
key to move your Address
cursor return
not r`1
use the return _Cf1J�J
key. ity/Town State Zip Code
2. System Owner:
Name -----
m7m
Address(if different from location)
City/Town State Zip Code
—617� -,?�_?-s, b-I -- - - ---
Telephone Number
B. Pumping Record LL
1. Date of Pumping / ? - 2. Quantity Pumped: ^ -
Date Gallons
3. Component ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes i No If yes,was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
u` c�S6 y�
ame Vehicle License Number
3ervloe Pumping&Drain Co.,Inc:.
Company II0�P-
North Reading,MA 01664
7. Location where cbn-tenfs were Isposed:
(4,4-7 -
Sign of Hauler Date
., Signature of Receiving Facllity(or attach facllity receipt) Date
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