HomeMy WebLinkAboutSeptic Pumping Slip - 134 CANDLESTICK ROAD 7/23/2018 on l u
RECEIVED
Sy
.4tem Pumping.Record "� �"� u" Q I I'M u Ik�.�� "4��°1
DEP has provided this forum for use=by local Boards of Health. Other forms may be'used,but the
information-roust be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submifle�d to
the local Board of Health or other approving authority.
A. Facility InforMati ,
1. System Location: Left/Right frpnt cf house, Leftif ht �P Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear®f building, Under deck
Address
City own Stag ZIp Code
2. System Owner: _
Marne
Address(if different from location)
clty/Town State Coyde�
'telephone Number
Pumping R r
4. Date of Pumping oat �2. Gluanfi pumped: Gaitons3. Type of system: Cesspool(s) ptic"Tank Tight Tank
E] father(describe):
4. Effluent Tee Filter present? (] Yes o if yes, was it cleaned? ® Yes ❑ No
' S. Condition of System:
6: System Pumped By:
Nell.Bateson • F5621
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. ZeH
ontents-were disposed:
Lowell Waste Water
Cate
t5form4.doc»06/03 System pumping Record a page 1 of 1