HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 84 CANDLESTICK ROAD 1/14/2021 : Commonwealth of Massachusetts - �
City/Town of JAN 4 2021
System Pumping Record �RSHANOC`FCt
Form 4 �pWN�F H pEPARSMENI
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 authonly.
A. Facility Information
1. System Location: Left/q*gfon�ofhou , Left/Right rear of house, Left/right side of house, LeftRight side of building, Lg building, Left/Right rear of building, Under deck
Address r�
CWrown State Zip Code
2. System Owner ��
Name
Address(if different from location)
CivTown Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;;eptic
Qu tity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Jaj
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle LFoense Number
Bateson Enterprises Inc
Company
7. Lo re contents�were disposed:
CAL S Lowell Waste Water
SjgAWeqtH&uWUDate
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