HomeMy WebLinkAboutSeptic Pumping Slip - 366 CANDLESTICK ROAD 4/17/2015 : \ I.00YII'T onweann OT IVIaSSacnuseus
_ City/Town Of .
�b 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/Righ#front of house,Q&V Righ ear of hous. Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righ rear o building, Under deck
Address '3 Jte,, c�k -`A
City/Town state Zip Code
2. System Owner. t
Name'
Address(if different from location)
Cityrrown ' State Zip Code
Telephone Number
B. Pumping Record , 7
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y—Y
3. Type-of.system: ❑ Cesspool(s) ' eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes,was it cleaned? ❑ Yes ❑ No
" 5. Condition of� �.(• f
6.. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo contents-were disposed:
Ci. S'. Lowell Waste Water
Sign a Heule e f
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