HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 CANDLESTICK ROAD 7/6/2021 Commonwealth of Massachusetts Ca FF I If E D
. City/Town of JUL 061021
System Pumping Record
Form 4 7-0,ARD OF HEALTH
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/4ig of hours , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 43
Cityt-rown State Zip Code
2. System Owner.
Name
Address(if different from location)
CiWTown State Zip Code
61 3f- 33 ?
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_flo 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. Locatio h contents were disposed:
_L S. Lowell Waste Water
Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1