HomeMy WebLinkAboutSeptic Pumping Slip - 280 CANDLESTICK ROAD 9/17/2015 : Commonwealth of Massachusetts
City/Town of
System Pumping.Record
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 <t
1. System Location: Left/Righ t of hous , Left/Right rear of house, Left./right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
i
CitylTown State C G��� Zip �
Telephone Number
t
B. Pumping (record �..
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes,was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
6: System Pumped By:
Neil.Bate ibn - F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Locati n where contents were disposed:
GLS*.D Lowell Waste Water
f
Sign a Haule Date
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