HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 CANDLESTICK ROAD 4/19/2022 Commonwealth of Massachusetts �J22
City/Town of APR PNoovE�a
b System Pumping Record
owNOFNO�pAa�M�N-c
Form 4
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 yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
I. S don: Left/Right front of house, Left/ Right rear of house, Left/right side of house, Lei
ight side o uilding, Left/ Right front of building, Left/Right rear of building, Under deck
on the computer, �l 1
use only the tab a� (
key to move your Av �1n ,
cursor-do not � 1 t �14 ILL MA
use the return City/Town State Zip Code
key.
2. S_ystam
/w/ner:
Name
rerun
Address(if different from location)
MA
CityrFown State ! _ Zip gode
r 1-X:5 02 —
TTelephone Number
B. Pumping Record
1. Date of Pumping ate a 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ;Locati where contents were disposed:
SD Lowell Waste Water 2
Signature of Hauler Date