HomeMy WebLinkAboutSeptic Pumping Slip - 210 CANDLESTICK ROAD 8/23/2017 Commonwealth of Massachusetts
CiWTown of
SOtem Pumping.Record
Form 4 , c
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., '
heck 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. Faciflity. Information 1
1. System Location: Left(Rigel t front of>7ause,�Left J Right rear of pause, Left/right side of pause, Left/
Right side of building, Li ran of 6uildirig, Left J Right rear of building, Under deck
Address
City('rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' State- Zip Code
`: ! (
Telephone Number r'
1.
B.
Pumping Record
1. ®ate of Pumping mat ---- uantity Pumped: Gallons
C
3. Type-of system: ® Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? Ej Yes OINO If yes, was it cleaned? ® Yes ® No,
' S. Condition of System:
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle Ucense Number
Bateson Enterprises Inc
Company
7. Lo ti®> wlae a canIt nts-were disposed:
GLS: Lowell Waste Water
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Sjgn$tufo 9t HaulDate
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