HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 CAMPBELL ROAD 7/3/2023 : Commonwealth of Massachusetts
City/Town of
z System Pumping Record 032023
Form 4 ,UL
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 Locatio : Left Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of bui , Left/ Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab Sic C.,,,ahe
key to move your Address
cursor-do not ,tv` i
use the return own Cit lf — MA � S
key. City frown Zip Code
2. System Owner:
rob
Name - - - -
nwn
Address(if different from location) —
MA
City/Town State Zip Code
S- �6 -
Telephone Number
B. Pumping Record
1. Date of Pumping Date 123
2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - / - - -- ---- -- - - -- —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tin_ey Mass F5821
Name Vehicle License Number
j Bateson Enterprises, Inc.
Company
7. ntion where contents were disposed:
Lowell Waste Water
----
C. -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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