HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 186 CANDLESTICK ROAD 11/19/2019 :&\_ Commonwealth of Massachusetts RECEIVED
City/Town of 00V 19 2.011
System Pumping Record 0FNORTHANWvER
Form 4 TO NTH DEPARTMBNt
DEP has provided this form for use-by local Boards of Health. Other forms may *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 Ib Th 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 ' t front of�of
, Left/Right rear of house, Left/right side of house, Left
Right side of building, lg ilding, Left/Right rear of building, Under deck
Address �S�_(C
City/Town State Zip Code
2. System Owner:
Name
Address(W different from location)
CitylTown stag t7
Telephone Number
B. Pumping Record
1. Date of Pumping Cate 2. Quanti Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? No
5. Condition-of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiq�ivffft contents-were disposed:
L S Lowell Waste Water
Signk4e qt HaWeV Date
t5 rmCdoa 06/03 System Pumping Record•Page 1 of 1