HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 CANDLESTICK ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
j system Pumping Record ,�`031013
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 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 : Leff Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of bu , eft/ Right front of building, Left/Right rear of building, Under deck
on the computer, ((
use only the tab 2� C"ri�1eS
key to move your Ad ress
cursor-do not 1j�t1CDlJQ� MA kG
use the return key. City/Town State Zip Code
2. System Owner:
UkC'r){-N &Uc�A
Name
�e�um
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date J/0 Z3 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 ElNo
5. Observed condition of component pu ped:
Ux{
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. nion where contents were disposed:
Lowell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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