HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 195 CANDLESTICK ROAD 9/9/2019 RECEIVED
: Commonweaith of Massachusetts r
City/Town of Ta/M OF K,-,.a,
V.
System Pumping Record " AL
fiWp '
Form 4
DEP has provided this form for us&by local Boards of Health. Other forms may be*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 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 house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name.
Address(ir different from location)
CityJTown $�� a
r
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Cond�a�f Sy�en �k� /i ^ -7�
y�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Loca' ere contentawere disposed:
G L S. Lowell Waste Water
Sign a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1