HomeMy WebLinkAboutSeptic Pumping Slip - 326 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-, '
heck 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
I. System Location; Left/ i , 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
CWrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown Ap Cade ;
f
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons c—?
3. Type-of system: ❑ Cesspool(s) �, 6e tic Tank `
. 1=J'� p ❑ Tight Tank
❑ Other(describe):
4. EffluWZee_Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste f
6; System Pumped By;
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locqfie where contents-were disposed:
G_ S Lowell Waste Water `.
Sign a qf Haule Date
t5form4.doc•06103 System Pumping Record•Page i of 1