HomeMy WebLinkAboutSeptic Pumping Slip - 235 CANDLESTICK ROAD 7/13/2016 Commonwealth of Massachusetts
Wn � %' t
System u1 111 gRecord
Form 4 '°a14 r
F �urd�
DEP has provided this ford for use-by local Boards of Health. Other for4 may p w d, but the
information must be substantially the tame as that provided here. Before using.tfbrm, 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: Left/ iaht front of hoes , 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 r
w
City[Town State Zip Code
2. System Owner. . .
Name'
Address(if different from location)
cityrrown ' State - Zi de ;
t..
Telephone Number
r ,
. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons —�`
3. Type of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neil.Bates®n - F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wv ere contents were disposed:
G L Q Lowell Waste Water
SianAtu a I Haul Date
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