HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 195 CANDLESTICK ROAD 1/31/2022 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record •
Form 4 JAN 312022
DEP has provided this form for use-by local Boards of Health. OhrCM
f jt tha
information•must be substantially the same as that provided here. inn check with you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/Wt rear of bQpse, Left/right side of house, Left
Right side of building, Left/Right front of building eft Righ re df building, Under deck
on the computer, / 2 < Q;* ,/,A Q
use only the tab / ri'y/(J!-� v l�
key to move your Adrqts ��� � Q! O `7
cursor-do not MA
use the return IL key. City/Town State Zip Code
dr__�1 2. Syjtem Owner:
PKk r
ame
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Address(if different from location)
MA
Cityrrown Stat /� Q 1� Zip Code
&S-g— lfl / /
Telephone Number
B. Pumping Record
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1 Date of Pumping ate 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ,
4. Effluent Tee Filter present? ElYeses'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
-
6. System Pump d By:
Jon Kirmil d*u Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc. _
Company
7. L "on where contents were disposed:
nGLSD Lowell Waste Water
Signature of Hauler IV Date