HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 210 CANDLESTICK ROAD 10/5/2020 "Fc
Commonwealth of Massachusetts row ooj ` F�
City/Town of s
System Pumping Record yoF��gti�
Form 4 T4P*PR
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
I. System Location: Lek RightAqutoLhouse, Left/Right rear of house, Left I right side of house, Left
Right side of building, Le /Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiortJ ere contents were disposed:
Lowell Waste Water
Sign a Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1