HomeMy WebLinkAboutSeptic Pumping Slip - 84 CANDLESTICK ROAD 5/17/2016 : 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.
A. Facility. Information
1. System Location: Left94 fight front of house 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
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State Zip de
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2• Quanti Pumped: Gallons i
3. Type of system: El Cesspool(s) eptle Tank [I Tight Tank
❑ Other(describe):
r--
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
U
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca.o h re contents-were disposed:
G L S:P Lowell Waste Water
qYraA
Sign Vtura Haul Date
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