HomeMy WebLinkAboutSeptic Pumping Slip - 333 CANDLESTICK ROAD 9/15/2015 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
1. System Location: Left/Right front of house Le /Righ ear of hous.,, Left/right side of house, Left/
Right side of building, Left/Right front of bui irig, Left/Rig rear of building, Under deck
Address __3
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown ' Stat%°'q t 7— (7 Code
Telephone Number
B. Pumping R'cord
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
" 5. Condition of.System-
C s �.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tion, mre contents-were disposed:
G L S. Lowell Waste Water
SignAtu fe cf Houlejj Date
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