HomeMy WebLinkAboutSeptic Pumping Slip - 211 CANDLESTICK ROAD 8/23/2017 -- —
RECEIVED
Commonwealth of Massachusetts
C4/Town of . 100M OF�NM
System Pumping.Record b
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms maybe 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 submitted to
the local Board of Health or other approving authority.
. A. Facility, Information
1. System Location: Loft/Right front of Mouse, Left Righ rear of Nous Left/right side pf house, Left/
Right side of building, Left/Right front of buitdirig, Lefty g�rear of building, Under deck
Address
6 V -(
City/Town State - Zip Code
2. System Owner:
Name'
Address(if different from location)
CityfTown - state Zip Code
p t�
Telephone Number
r
Pumping Rqcord
1. bate of Pumpingoa �--�----�y-� 2. uantity Pumped:
Gallons �.
3. Typo-of system: ❑ Cesspool(s) ® Septic Tank [I Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? d Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Nell.Bateson - F5821 j
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loco' n-� ere contents-were disposed:
C�.�.S Lowen Waste Water
-r/10, A
Sign a Houle Date
l5form4.doc-06/03 System Pumping Record•Page 9 of 1