HomeMy WebLinkAboutSeptic Pumping Slip - 333 CANDLESTICK ROAD 12/28/2016 Commonwe'alth of Massachusefts FIZE, ;EIVE
Syitem Pumplln§-
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Form 4
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®lip has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information must be substantially the tame 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.
I. System Location: Lift!Right front of lious , Le Ri t rear of house,,)Left/right side of house, Left f
Right side of building, Left/Right front of bul adg, Left ig rear of building, Under deck
Address 2
City/T'own _ State Zip Code
2. stem Owner:
Y
Name'
Address(if different from location)
Cityfrown State Zip Code
� R
�_
'telephone Number
• � r
f
Pumping W j
1. Date of pumping ote ACC` 2. (quantity Pumped: Gallons
. Type•of system: El Cesspool(s) pticTank D 'Tight Tank
Other(describe):
4. Effluent Tee Filter present.? El Yep o If yes, was it cleaned? Yes No
6. Condition of.System*
6: System Pumped Sy:
Neil.Batesiari F6821
(Name vehicle License Number
Sateson Enterprises Inc-
Company
7. Lo do ere contents-were disposed:
P S: Lowell Waste dater
Sign a H.Iule Cate
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