HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 CANDLESTICK ROAD 1/14/2021 : Commonwealth of Massachusetts
_ • City/Town of JAN 14 2021
System Pumping Record TOWN OF NORTH MDUVER
Form 4 HEALTH DEPART"AENT
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 house, Left/Right rear of house, Left/ . ht side of hou Left
Right side of building, Left/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 locafion)
city/Town State ` Zip e.
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.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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