HomeMy WebLinkAboutSeptic Pumping Slip - 365 CANDLESTICK ROAD 12/28/2016 µ
..,C\ Commonwelalth of Massachusefts ?-0 1(3
Cit�/Town of
Form 4
C EP has provided this form for use-by local Boards of Health. Other forma may be used,but the
information must be substantially the Larne as that provided hare. 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.
® Facility. Inform tion
9. System Location: Left/Right front of hour , e l lg rear of hdus. Left/right side of house, Left/
Right side of building, Leff/Right front of iding, Left uilding, Under deck
UL
Address ��` C" �. —
/'�
City/Town state Zip Code
2, System Owner.
Name`
,address(if different from location)
cityfrown St at 1 Code
Telephone Number �t
.6.—Pumping Record -
'l, Date of Pumping pate 2. Quantity Pumped: Gallons
. T yp e-of s stem. Cesspool(s) eptic Wank Tight Tank `
El Other(describe).
4. Effluent Tee Filter present'? 0 Yep No If yes, was it cleaned? 0 Yes Ej Igo,
" 5. condition of Systern �✓"��G,, � .,�� �� �� �'L
6. System Pumped By:
Neil Batesibn F6821
Name Vehicle License number
ateson Enterprises Inc-
Company
T. Lo ti re contents-were disposed:
•, L T Lowell Waste Water
Sign ge M aui mate
I
t5form4.doc-o6/03 System Pumping Record Page I of I