HomeMy WebLinkAboutSeptic Pumping Slip - 280 CANDLESTICK ROAD 4/11/2016 Commonwealth of Massachusetts
City/Town oi
A P F1,
System Pumping.Record
]'0Y11f1 OF"
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 tame as that provided here. Before using.this form, check with your
local Board of Health to determine the forth 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 KKI t�iro of use'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
V'
City/Town State Zip Code
2. System Owner
Name'
Address(if different from location)
city/Town state Zip Co
Telephone Number
B. Pumping Rpcord
1. Date of Pumping 2. Quantity umped:
Date --ty Gallons
3. Type-of.system. ❑ Cess ool s) e ptic Tank E] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ED-No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: [LW(k
6; System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Ba!eson Enterprises Inc ....
Company
7. Locafion,where contents-were disposed:
Lowell Waste Water
Sign$t4uFqta_Haute
Date
t5form4.doc•06/03 System Pumping Record Page 1 of 1