HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 333 CANDLESTICK ROAD 4/19/2022 Commonwealth of Massachusetts RECEIVED
City/Town of APR 19 2022
S stem Pumping Record46
Y TOWN OF NORTH ANDC".
Form 4 HEALTH DEPARTMEN?
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
1. System Location: Left/ Right front of house, Left/ ear o e, Left/right side of house, Lei
Right side of building, Left/Right front of building, eft gh(Z!�j building, Under deck
on the computer, el
use only the tab (-Aki
J _
key to move your Ad reel� 'IOL A� ^ I j�
cursor-do not �(� MA
use the return /Town State Zip Code
I key.
�1 2. System Owner:
i
Name
I rtvn
Address(if different from location)
MA
Citylrown Sta--_t%--%/ Zip Co e
Telephone Number
B. Pumping Record '__
1. Date of Pumping Date 2. Quantity Pumped: Gallons
1 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 componen pumpe
6. System Pumped By:
David Tiney Mass F5821 _
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Lo here contents were disposed:
eL5
Lowell Waste Water
Signature of Hauler Date