HomeMy WebLinkAboutSeptic Pumping Slip - 103 FULLER ROAD 3/22/2016 Commonwealth
RECEIVED
Q i own of
System Pumping-Record
aI A LI H DFAF 7Wf:'JNT
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. Infor atti n
1. System Location: Left __i_ ht front of hour 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 ,� � n � �•
City/Town State Zip Code
2. System Owner,
Name'
Address(if different from location)
Cityfrown Stat Zip Code
Telephone Number —3
Pumping Record �
1. Date of Pumping Date 2. Quantity Pumped: /✓{
Gallons
3. Type of system: ❑ Cesspool(s) Q,,S ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of.System:
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca' n contents were disposed:
G L S Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1