HomeMy WebLinkAboutSeptic Pumping Slip - 326 CANDLESTICK ROAD 4/24/2018 Commonwealthf Massachusetts
w iWTown of
MIR " 018
SY,4tem Pumping.Record
Form 4 ��. ,�.��6
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 submitted to
the local Board of Health or other approving authority.
A. Facility, InforMation
1. Syitem Location: Left/Right front o. f house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
' Atama' 4
Address(if different from location)
cityfrown ' State ZIP Code
F Telephone Number
1;
.............----------
.13. Pumping
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. T
e-of s o- i.
Type-of stern:y• ® Cesspool(s) ' (,�-ae"ptic Tank � Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? ® Yes ® No,
5. Condition of system: �j
6: System Pumped By:
Neil.Batesbo F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo re content,&were disposed:
G L 5: Lowell Waste Water
C �
• r
Sign a Hbui Crate
WbrmCdoc-06/03 System Pumping Record m Mage 1 of 1