HomeMy WebLinkAboutSeptic Pumping Slip - 134 CANDLESTICK ROAD 9/15/2016 : Commonwealth of Massachusetts
City/Town of ' ' °
System Pumping-Record 9 2C)Mi
Form 4
DEP has provided this form far 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: Left/Right 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 ,.--� A '
Citylrown State Zip Code
2. System Owner. '
Name*
Address(if different from location)
citylrown State Zip ¢e
j
Telephone Number
i
.B. Pumping ✓RRecord
1. Date of Pumping D 2. Quantity Pumped:
ate
-- -
Gallons r
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent.Tee Filter present? ❑ Yes a4o If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of �t��
SY s
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location
where contents-were disposed:
G S: Lowell Waste Water
SignAtufe qf Haute Date r
I
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