HomeMy WebLinkAboutSeptic Pumping Slip - 168 Campbell Rd - 12/05/2024 - Septic Pumping Slip - 168 CAMPBELL ROAD 12/5/2024 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 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 within 14 days from the pumping date in
accordance with 310 CMR 15,351
HOUSE: front back(side)rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1, System Location:
on the computer,
use only the tab lco� ----------
key to move your Address
cursor-do not 0_0�6� MA 0 1
use the return
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from locaiTon_)_
MA
City/Town State dip Code
-telephone Number
B. Pumping Record
11_1
1. Date of Pumping ate 2. Quantity Pumped.
Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
7 Other (describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? ❑ Yes 7 No
5, Observed condition of component pumped:
Q0 r
6. System Pumped By:
Dave Tinny MasslAA95E Ma76�AD31 Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. !on where contents were disposed:at C�SD)Signature of Hauler Date
_Signature of Receiving-Facility(or attach facility receipt) -Date
t5form4.doc- 11/12 System Pumping Record-Page 1 of 1