HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 CANDLESTICK ROAD 4/28/2020 Commonwealth of Massachusetts cD
City/Town of kPR 2 g 10
System Pumping Record 100cfWJM
Form 4 j jp,►.�
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 forrh 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 �ig
front house,,Left/Right rear of house, Left/right side of house, Left
Right side of building, of of building, Left/Right rear of building, Under deck
Address t
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumpingr. 2. Quantity Pumped:Date p Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contentsr were disposed:
G L S`-P Lowell Waste Water
IV6 YXI
SignAtule Naul Date
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