HomeMy WebLinkAbout- Septic Pumping Slip - 210 CANDLESTICK ROAD 8/28/2018 Commonwealth oRE � {
CitWown o .
Sy6tem Pumping,Record
Fi EM_C Hl:6'M'FIMh''.NT
DEP has provided this form for use-by local Boards 6f Health. Other forms may be`used,but the
information`must be substantially the tame as that provided here. Before using.this fora,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. Facipty, Inform' ation
1. System Location: Left ft
ront of itious2eul
Left/Right rear of house, Left/right side of house, Left/
Right side of building, Lefg ldifig, Left/Right rear of building, Under deck
Address t q
I
citylrown State Zip Code
2: System Owner
6>
• Name'
Address(if different from location)
Cityrrown ' State, e ;
• f
"telephone Number
ID
t
.B. Pumping Ripcord
t�)
1. ®ate of Pumping Date2. Quantity Pumped:
Gallons��"
3. Type-of system'*y.stem:
Cesspool(s) eptic Tank D Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present'? Yes o If yes, was it cleaned? El Yes ❑ No,
5. Condition of System: �ft ry
6.• system Pumped By:
Nell.Bateson ' F5621
Name Vehicle Ltcense Number
Bateson Enterprises Ino
Company
?. Locati�a re contents-were disposed:
Lowell Waste Water
' F
Sign a Houle Date
i
15form4.doc•06/03 System pumping Record d page 1 of I