HomeMy WebLinkAboutSeptic Pumping Slip - 211 CANDLESTICK ROAD 8/15/2018 Commonwealth of Masu
City/Town of CEI
SyMem Pumping.Record AN 1 `5 Z018
100 ��� � 1m l
DEP has provided this form for use=by local Boards 6fflealth. Other form ��h..°� . � , �
e ; iut the
information,must be substantially the tame as that provided here. Before using.this farm,check with your
local Board of Health to determine the form they use.The Systern Pumping Record must be submitted f:c
the local Board of Health or other approving authority.
A. Facipty InforMationr
1. System Location: Left/Right front of house, Left 101 h;irea;rof:h use, Left/right side of house, Left/
Right side of building, Left/Right front of building, Leftear df building, Under deck
Address
Ci Yfrown -'\ State Zip Code
2. System owner: � ��• C.7
' Name'
Address(if different from location)
Cityf own ' State Zip Code
sf
'telephone Dumber r
i
f
Pumpling Record
1. bate of Pumping ®ate 2. Quantity Pumped: Daltons
3. Type-of.system: 0 Cesspool(s) eptic Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? El Ye. o If yes,was it cleaned? [ Yes El No,
' S. Condition of System: 01���? •
fR
6; System Pumped Ey:
Neil.Eatesio� ' F5821
Name Vehicle License Number
Bateson Ehte rises Inc'
Company
7. L re contents-were disposed:
L S Lowell Waste Water
Sign Houle Cate
k5form4.doc-06/03 System pumping Record.page 1 of 1