HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 9/2/2020 .� Commonwealth of Massachusetts RECEIVED
City/Town of SEP G 2 2. N
System Pumping Record 'TOWN0'NORTH8DEPA DEPARANDOVTMENT
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Form 4 HEALTH DEPARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 house, Left Right rear of hous. Left/right side of house, Left
Right side of building, Left/Right front of building, e g rear of building, Under deck
Address
CWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown Stat _Zip Code
Telephone Number
B. Pumping Record
l J
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic"Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes alxo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: � 2���'�-
l
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locat01.where contents-were disposed:
-' G L S. Lowell Waste Water
Sign a Haul Date
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