HomeMy WebLinkAboutSeptic Pumping Slip - 280 CANDLESTICK ROAD 4/24/2018 Commonwealth of Massachusetts
City/Town o f
SyMem .Record
®EP has provided this forrri for use-by local hoard o#Health. Other forms ma t",information•must be substantially the same as that provided here. Before using.thiriri,check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
oC1i1 Information
�. System Location: Lft1.
;4fr ftt �Iouseeft/Right rear of houses, Lei/right side of house, Left/
Right side of building, Leigh rMg, Left/Right rear df building, Under deck
Address
Cityrrown State zip Code
2, System Owner: � • .,
Name'
Address(if different from location)
City/Town Sfaf zip Cam ;
fele hone Number
er
f
Pqmping Kecord
1. bate of Pumping Date 2. Quantity Pumped: Gallons
3. Type•of systerri: Cesspool(s) eptic Wank 0 Tight Tank ,.
® tither(describe):
4. Effluent Tee Filter present? ® Yep o if yes, was it cleaned? ® Yes ® No,
' S. Condition of System:
6. System Pumped 6y:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lose' here contents-were disposed:
Lowell Waste Water
a r
Sign @ hiaule Date
t5forrn4.doc^06/03 System Pumping Record a Peg*e i of 1