HomeMy WebLinkAboutSeptic Pumping Slip - 100 CANDLESTICK ROAD 6/19/2018 Commonwealth of Massachusetts
u City/Town of
- 0 System Pumping Record
Y F Vr ✓0
Form 4
DEP has provided this form for use by local Boards of Health. h t the
information must be substantially the same as that provided her eck 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: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of housRight rear afI'ci❑ :°w eft rear of building. Right rear of building.
Address
Cityrrown State Zip Code
2. System Owner:
w
Name
Address(if different from location)
CitylTown State./` Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: -
Date Lallans
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): -—
4. Effluent Tee Filter present? ❑ Yes [I-Na— If yes, was it cleaned? ❑ Yes ❑ No
5. Conditin of System t
(. -.
6. Systerh�ped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.L D Lowell Waste Water
--------
qgrpture of Haul r Date
i
t5form4.doc•06/03 System Pumping Record•Page 1 of 1