HomeMy WebLinkAboutSeptic Pumping Slip - 195 CANDLESTICK ROAD 3/8/2016 Com
mon wealth of Massachusetts
= u . % . oW .
r
o Pumping,Record
Form 4
DEP has provided this ford for us&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. In or ati n
I. System Location: Left/Right front of house, Left/el ht_rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rr-Right rear of building, Under deck
Address E l /� (e � U d"�/ C - .,
' `
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown staje Zip Code ;
'telephone Number
B. Pumping P�"
u.
1. Date of Pumping gate 2. ttity Pumped: Gallons Y
3. Type•of system: ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? ❑ Yes ❑ No,
5. Conditi f System-
6.- System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haule Date
t5form4,doc-06/03 System Pumping Record•Page 1 of 1