HomeMy WebLinkAbout- Septic Pumping Slip - 280 CANDLESTICK ROAD 9/24/2018 Commonwealthof Massachusefts
it /T own ofSyitem .
plr -Record
Form 4
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DBP has provided this farm far use-by local Boards of Health. Other farms may be used, but the 1
information-must be substantially the tame as that provided here. Before using.this faun,check with your J
local Board of Health to determine the forth they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facfl Informiation ,
1. System Location: L� �ti ,ht jfronty �se, Left/Right rear of hausl~, Left/right side elf house, Left of o
Fight side of building, fight front of building, Left/Right rear of building, Under deck
AddressA
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Ciwrown ' State
p Telephone NumberR4
1
Pumpling Record
1. bate of Pumping sate 2. Quanti Pumped: Gallons `
3. Type,of system: El Cesspool(s) ptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o if yes, was it cleaned? 0 Yes ® No.
5. Condition of System:
6: System Pumped By:
Neff.BatesTon P5821
Name Vehicle License Number
Bateso i Ehterprlses Inc
Company
7. Location-wh re7ontentawere disposed:
C S Lowell Waste Water
b (7/ C
Sign a htsule lu
Date
t5form4.doca 06/03 System Pumping Record.Page 9 of 1