HomeMy WebLinkAboutSeptic Pumping Slip - 174 CANDLESTICK ROAD 10/1/2015 1
Commonwealth of Massachusetts
= City/Town of .
y item. Pu pin r
Form 4 (10 1)
DEP has provided this form for use=by local Boards of Health. Other form's may;be'used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your t
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
I. System Locatio Let ightont of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron o uildirig, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown State Z�p.Code ;
Telephone Number
B. Pumping Record ..
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6; System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca,jon-wh.a contents were disposed:
L S: Lowell Waste Water
F
SjgnA a qt Hauls Date
t5form4.doi.-06/03 System Pumping Record•Page 1 of 1