HomeMy WebLinkAbout- Septic Pumping Slip - 19 CANDLESTICK ROAD 10/19/2018 Commonwealth ®f Massachusetts
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System Pumpling Record
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DEP has provided this form for use-by local Boards of Health. Other forms may be bled, 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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of douse /Right 6r of house>Left/right side of house, Left
Right,side of building, Left/Right front of building, Left/Right rear df building, Under deck
Address
�dD `✓ ..
CdyiCown Mate Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town state- Zip Code
Telephone Number
Pumping
1. Bate of Pumping oat - - udntlty Pumped:
Gallons
3. Type-of system: Cesspool(s) Septic Tank Tight Tank
® Other(describe):
41. Effluent Tee Filter present? [] Yes No If yes, was it cleaned? ® Yes ❑ No
5. Condition of System: �Jlo(iM.k (---ttQ,K
6. System Pumped By:
Pfeil.Batesbn F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loco nrcw ere content%were disposed:
C L a: Lowell Waste Water
s€gn e Fi�uie Date
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