HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 43 CANDLESTICK ROAD 8/10/2020 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 10 20?.0
System Pumping Record TOM OF t��
Form 4 W-WN
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 hous , Le / ig ear o ouse,X.eft/right side of house, Left
Right side of building, Left/Right front of bui ing, Left/ ig rear 6 building, Under deck
Address L� �
Gb
CWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stated _ Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: t f_ LPN-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca. w contents were disposed:
Lowell Waste Water
Sign a Haul Date
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