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HomeMy WebLinkAboutSeptic Pumping Slip - 365 CANDLESTICK ROAD 5/1/2018 Commonwealth f Massachusetts -RECEIVED City/Town ofMAY ?018 A RecorduWy •�iyV I'N .�V`W P,��.Y wP P.����.V"'�u �.� V"�n i4 MP'N DEP hes provided this ford for use-by local Boards©f Health. Other forms may be'used,but the information'must be substantially the tame as that provided here. Before using.this forret,check with your local Board of Health to determine the forret they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority, A. Facift. Inform' ation 1. System Location: Lei/Right frprtt of House, Lei/ g of hous01 Left/right side of house, Left I Right side of building, Left/Right front of building, Left/Right rear of building, tinder deck Address City/rown State Zip Code 2. System Owner: Name' Address Of different from location) CitytTown State Zfp Code 'telephone Number ID r .B. Pumping Rpeord r 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-of system: El Cesspool(s) eptic Tank Tight Tank [� Other(describe): 4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes ® No, 5. Condition ofst m: I ,( S.` System Pumped By: Nell.Batesion ' F5821 Name Vehicle License Number _Beeson Enterprises Ina Company 7, Lo n�+vhere contents-were disposed: G Lowell Waste Water Sign aMauiKu — Date t5form4.doca 08103 System Pumping Record Page 1 of 9