HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 220 CANDLESTICK ROAD 4/9/2021 : Commonwealth of Massachusetts
City/Town of APR OD 2021
System Pumping Record ,�� OF HEALTH
Form 4
DEf has provided this form for use-by local Boards of Health. Other forms maybe*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•pagft, Lefft
igMRIg '
ront of Iiou , Left/Right rear of house, Left/right side of house, Left
Right side of bu' ron of building, Left!Right rear of building, Under deck
Address
cftyn'own state Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gauons
3. Type-of system: ❑ Cesspool(s) 3-se-5-tic-Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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 contents-were disposed:
.L S Lowell Waste Water
J�
Sign aqt Hbuleiv Date
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