HomeMy WebLinkAboutSeptic Pumping Slip - 315 CANDLESTICK ROAD 11/10/2015 Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for usez 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 .. !{ Righ ro �ront house Left/Right rear of house, Left/right side of house, Left/
Right side of b 'ldih ice, Left/Rig of building, Left/Right rear of building, Under deck
• Address
City Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown S ip Code
Telephone Number '
i
B. Pumping Record ..
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ateptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of Sys
oz- >�6Lk
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca'o ere contents were disposed:
G L S. , Lowell Waste Water
g � C
Sign a 9t Haule Date
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