HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 186 CANDLESTICK ROAD 7/1/2020 Commonwealth of Massachusetts RECEIVED()
City/Town of JUL 0 1 2oZ
System Pumping Record TOWN LT NURTHAMENT
Y p 9 HEALTH DEPARTMENT
Form 4
DEP has provided this form for us&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 Ri ht` nt of hou ft/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
City/Town l State Zip Code
2. System Owner.
Name"
Address(ir different from location)
CitylTown Sty I—VJ zp( [e�
Telephone Number
.B. Pumping Record
1. Date of Pumping fate 2. Quantity Pumped:
Gauons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No
5. Condition of System:
��Vt,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where-content&were disposed:
L S Lowell Waste Water
Sign We cfH6uIerU Date
t5 =4.doc•0&03 System Pumping Record•Page 1 of 1