HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 333 CANDLESTICK ROAD 9/20/2019 Commonwealth of Massachusetts PIS
City/Town of
System Pumping Record SEP 2 o 20N
Form 4 TOWN OF NORTH ANDOV_ER
S irn T,_ APART'..
DER has provided this form for use=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 hou , Le� ig ear sous. 'Left/right side of house, Left 1
Right side of building, Left/Right front of frig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping (� , 2. QuantityPumped: �
Datep Gallons
3. Type of system: ❑ Cesspool(s) [}-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D'No " If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbri F5821
Name Vehicle License Number
BateSOn Enterprises Inc
Company
7. Locatigoamthere contentawere disposed:
�L Lowell Waste Water
-� -7 --�
Sign a Haul Date
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