HomeMy WebLinkAboutSeptic Pumping Slip - 100 CANDLESTICK ROAD 7/31/2017Commonwealth of Massachusetts
City/Town of .
System Pumping. Record
Form 4 .
DEP has provided this form for 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 submitterd .to
the local Board of Health or other approving authority.
. A. Facility Infortillation
1. System Location: Left / Right front of house, Left / Right rear of hous. / right Ide of house Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
C1�,-taW�hG c1t klcCi
City/Town State - Zip Code
2. System Owner.
Name 0140C
Address (if different from location)
City/Town '
State. Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping tza 17 2 ant€ty Pumped: Gallons f
3. Type -of system: ® Cesspool(s) ®' Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6: System Pumped By:
Neil. Batesbn •
' Name
Bateson Enterprises Inc
Company
7. Locatip R ! ere contents -were disposed:
G L S. , Lowell Waste Water
Sign e • Haul
If yes, was it cleaned? ❑ Yes ❑ No,
1
Fa821
Vehicle license Number
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