HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 10/1/2019 : Commonwealth of Massachusetts
City/Town of
System Pumping Record OCT 01 2011q
Form 4
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 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: Le 'ght front of Fious�, 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
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityffown zi
Telephone Number
B. Pumping Record
1. Date of Pumping Dab 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) p'c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes O_No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditioner tem:u C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo contents were disposed:
G L S Lowell Waste Water
_C {
Sign afH!kUlNU Date
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