HomeMy WebLinkAbout- Septic Pumping Slip - 95 CANDLESTICK ROAD 10/31/2018 Commonwealth f Massachusetts
s r City/Town of qM
System Pumpling Record
Form 4 Tovol OF NORTH a i MOOV :R
New 6 G.wr4d p u Al i"/ w E L T
DEP 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 fora,check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to 1
the local Board of Health or other approving authority.
A. Facility infor ti n
�, system Locaation a Ricr t-bf hour Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left I Rig�`Tf f`1buiidlfig, Left I Right rear of building, Under deck
Address ...
Cityfrown State zip Code
2. System Owner:
Name'
Address(if different from location)
Telephone Number
Pumping
1. Date of Pumping rate 2. Quantity Pumped: gallons
3. Type-of system: El Cesspool(s) eptiC Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ej Yes If yes, was it Cleaned? ® Yes El No
5. Condition of system:
6. System Pumped By:
Nell.6ates7on F5821
Name Vehicle License Number
_Bateson Enterprises Ina
Company
7. L r r contents-were disposed:
G L 5 Lowell Waste Water
Sign a qt Haul mate
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