HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 CANDLESTICK ROAD 5/20/2022 :�L\l Commonwealth of Massachusetts
C4/Town of MAY 2 0 2022
System Pumping Record •
NORTH
Form 4 TO NN Of
DEPARTN NTEF�
DEP has provided this form for use-by local Boards of Health. Other forms may *used, but the
information,must be substantially the same as that provided here. Before using.this form,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 Information
1. System LocaRT
Lefront o se, Left/Right rear of house, Left/right side of house, Left
Right side ofinigh or o building, Left/Right rear of buiidfng, Under deck
on the computer, s /use onl the tab �TfZ
key to move your Ad ress
cursor-do not )61 y G�� MA
use the return - �
key.
ity/Town State Zip Code
VQ 2. S m Owner:
Name
renm
Address(if different from location)
MA
CityrTown State Zip Code
3�
Telep one Number
B. Pumping Record
\� kp?�
1. Date of Pumping 2. Quantity Pumped: Gallon�
Date s
s
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Y No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:^^^^
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. L here contents were disposed:
GLS Lowell Waste Water
Signature of Hauler Date