HomeMy WebLinkAboutSeptic Pumping Slip - 19 CANDLESTICK ROAD 12/13/2016 : Commonwealth of Massachusetts
CitYr/Town of
RECEIVED
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other frru the
Information must be substantially the same as that provided here. BefoVEeidt' is Farm,check with your
local Board of Health to determine the forr'ri 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 hiou Peft , ig r ar of haws Left/right side of hawse, Left Right side of building, Left/Right front of bueft/Rig rear of building, Under deck
Address
Citylrown State Zip Code
2: System Owner.
Uj �4 jf v�C/
Name.
Address(if different from location)
City/Town State X%Code
Telephone Number Jt.
z
i
.B. Pumping kacord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons --`
3. Type-of system: ❑ Cesspool(s) eptic-T9nk ❑ Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0446--' If yes, was it cleaned? ❑ Yes ❑ No,
' 6. Condition of System:
l c
Y "
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location who re contents-were disposed:
Lowell Waste Water
UPaA
Sign a cf HtulerU Date
t5farm4.doc•OB/03 System Pumping Record«Page 1 of 1