HomeMy WebLinkAbout- Septic Pumping Slip - 336 CANDLESTICK ROAD 10/4/2018 f EMMED
Commonwealth of Massachusefts
CitKown of 0C 1 0 0 1
SY,4tem Pumping,Record TOW'q OF �q()RTH AMMV[11
Form 4 its I.isi DDNU'�`[M[`i,fl`
DEP ha'-provided this fbim'for us&by local Boards 6f-Health. Other forms may be bsed,b'ut the
information,must be substantially the tame as that provided here. Before using.this form,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. Facfltty. Inform' aflon
1. System Location: Left. /Right front of house, Left I Right rear of.house, Left, right side o'f house, Left,/
Right side of building, Left Right front of building, Left Right rear of building, Under deck
Address
Zi-ii7f—own Mate Zip Code
2. System Owner
Aj\,
Address Of different from location)
Cityfrown State- Zip Code
'telephone-Nume r
.B. Pumping k-ecord
1. Date of Pumping Date 2. Quantity Pumped: G I allo-ii-s-
3. Type-of systerri. 0 Cesspool(s) 0--le-'pfic Tank D Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yes awo If yes, was it cleaned? Ej Yes ❑ No,
5. Condition of Sy
stem:
5xrv-�- k t1-0-lue�k_ -t^-
6.. System Pumped By:
Neil.Batesprt F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. G Lora'�here contents•were disposed:J� 7
M L Lowell Waste Water
-07
Sign
a H6111 n a Date
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