HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 6/24/2021 :-C\- Commonwealth of Massachusetts
= City/Town of
System Pumping Record RECE�
Form 4 y� ? 4 202�
�o'`v�R
DEP has provided this form for use-by local Boards of Health. Other forms may be bsed; e "
information must be substantially the same as that provided here. Before using.this form eck 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/erg orht f nt of�ioufse�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
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown stater Zip,Qode
Telephone Number
B. Pumping record
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: t,
LA-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocationAvhere contents,were disposed:
Lowell Waste Water--ff LOA Bc�L ��
/1
Sign a Haul Date
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