HomeMy WebLinkAboutMiscellaneous - 235 CANDLESTICK ROAD 8/14/2015 Commonwealth of Massachusetts RECEIVED
City/Town of
S ,/
System Pumping,lRecord
4
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be'used, b'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
t rear of house, Le right side of house, Left
System Location: Le j4fr-o—rant of house Left Right
Right side of building, 5��/Rjght Right "ffbi6ildirig, Left/Right rear of building, Under deck
Address —
5
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown Sta Zip Code
5 114-- tc,
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of systent. ❑ Cesspool(s) 3-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition ofSystqm: .
6.- System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafi"hqre contents were disposed:
G-LS*-Q Lowell Waste Water
Sign e AHaule Date
t5forrn4.doc-08103 System.Pumping Record•Page 1 of I
