HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 57 CANDLESTICK ROAD 10/1/2019 _ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP 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 house, Left/Right rear of hous. 1!�&�
Left
Right side of building, Left/Right front of building, Left/Right rear of building,ding,
Address
CityRo" State Zip Code
2. System Owner. C-4 �
Name'
Address(if different from location)
Cityfrovvn ;31 �- `�. rip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 QuantityPumped:
Date p Gallons
3. Type-of system: ❑ Cesspool(s) aSd_p`tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No
5. Con *on of t y�
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
G L.S. Lowell Waste Water (� r
2
Sign afHtulfflu Date
t5fbrm4.doa 06/03 System Pumping Record•Page 1 of 1