HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 CANDLESTICK ROAD 5/17/2021 .-C\- Commonwealth of Massachusetts RECEIVED
City/Town of f IAY 17 M1
N. System Pumping Record
Form 4 H ANDOVER
I A'_,'. - -PARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may 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/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
My/rown State Zip Code
2. System Owner.
Name
Address(Ir different from location)
CitylTown State 3a� �Trp code
Telephone Number J
.B. Pumping Record
1. Date of Pumping Dale 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
L S Lowell Waste Water
Sign a HauleiUj Date
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