HomeMy WebLinkAboutSeptic Pumping Slip - 211 CANDLESTICK ROAD 8/3/2016 : Commonwealth of Massachusetts
City/Town o€. .,m 'QED
°... w ��:
System Pumping-Record _ ' _:3 >:�
Form 4
DEP has provided this form for use=by local Boards of Health. Other forniiMiy' `6$k�ut 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. Intorlrrflation
1. System Location: Left 1 Right front of house, Le ig t rea;rear h sou e- eft.I right side of house, Left I
Right side of building, Left 1 Right front of building, of building, Under deck
Address
Citylrown state - Zip Code
2, System Owner:
�r
Name'
Address(if different from location)
CityTrMn ' State Zip Code ;
'telephone Number f 3
.B. Pumping Record
1. Date of Pumping r 2. Quantity Pumped: L
Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye_s OM6-� If yes, was it cleaned? ❑ Yes ❑ Na
' 5. Condition of System:
e
6. System Pumped By:
Neil.Bateson (=5821
Name Vehicle License Number
Bateson Elite rises Inc'
Company
7. Location where contents-were disposed:
S: Lowell Waste Water
Wa OA A?)
Sign a 9f Haule Date
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