HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 19 CANDLESTICK ROAD 5/24/2021 : Commonwealth of Massachusetts RECENM
City/Town of
MAY
System Pumping Record TOWN® NURIHANDUVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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 housL_e, /Rig rear of ous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/ ar of building, Under deck
Address Cq Ca.A,,A-Me SJ
Cwrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CityiTown Stater
r Zip Code
C��S=ac a
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [-S`eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Fitter present? ❑ Yes a'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
LOA 6-)����
S-igngt HauleV Date
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