HomeMy WebLinkAboutSeptic Pumping Slip - 100 CANDLESTICK ROAD 5/22/2018 Commonwealth of Massac
1 n of
MAY 2 2 201B
Qrm 4 TOWN OF NORTH ADO
HEALTH DU 'FMENI
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
information-roust 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 Inform' ation
1. System Location: Left/Right front of douse, Left/Right rear of house,C right e f hus�oLeft
Dight side of building, Left/Right front of building, Left/Right rear of bur ding, Under deck
. Addis
cityrrown state Zip Cade
2. System towner:
Noma'
Address(if different from location)
city/"fown ' Stater Zip Code
. P f
Telephone Number r' ;
i
PuImping Rqcord
1. Date of Pumping Date Z. Quantity Pumped: Gallons
3. Type-of system. Cesspool(s) eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ® Yes ® No,
5. Conitio of System-
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca era contents-were disposed:
S: Lowell Waste Water
fgn Vqi i Houle Cate
t5form4.doc•06/03 ;System Pumping Record a Peg*e 1 of 1