HomeMy WebLinkAbout- Septic Pumping Slip - 292 CANDLESTICK ROAD 10/19/2018 Commonwealth of Massachusetts
City/Town of
system Pumpingr 1 F oRl"
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Form 4
CEP has provided this form for use-by local Boards of Health. Other forms maybe used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your
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. i
Facility Infor Mation
1. system Locatio Oneg,
/Rig tort of house, eft/Right rear of house, Left•/right side of house, Left
Right side of bullLeft/Right ron o ul ding, Left/Right rear of building, Under deck
Address pp
l _
state Zip Code
City/Town
2. System Owner.
chi
Name"
Address(if different from location)
Cityrrown stater Zip Code
-7,ie-C-
'telephone Aumber
Pumping cot
1. Date of Pumping 2. -bntity Dumped:
Date Gallons
. TypeW system: ElCesspool(s) Septic Wank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes �4o If yes, was it cleaned? ® Yes ❑ No
5. Condition of System:
. System pumped By:
Neil.Sates-og F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location ere contents,were disposed:
G L S. Lowell Waste Water
Sign a cf Houle Crate
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