HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 95 CANDLESTICK ROAD 10/5/2021 Commonwealth of Massachusetts C'_VVED
City/Town of
System Pumping Record �ODFNpRTHANDO`1�
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the
informations 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 Locatio e g front%�hou
se, Left!Right rear of house, Left/right side of house, Left 1
Right side of bur n�/ Ig of building, Left/Right rear of building, Under deck
Address �
Cityrrown State Zip cotle
2. System Owner.
Name'
Address(if different from location)
CitylTown Statr^� P Codo
Telephone Number "t
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑- S6ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [J-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��� ` A ��� �✓�� a � `��e`�
6. System umped By:
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S.P Iki
L6wellWaste Water
VOU11)
- � a - a�-�
Sign a qfH116W Date
5form4.doc-06/03 System Pumping Record•Page 1 of 1