HomeMy WebLinkAboutSeptic Pumping Slip - 98 FULLER ROAD 5/17/2016 Commonwealth
i wn of
Pumping,System r•
Form
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 aticn
System ft/ i t front of hous. ,..
I. Right side of bu Idlrre� gk1"` - ° - ej�Left/Right rear of house, Left/right side of house, Left/
g �-g, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Code
2. System Owner.
�-.1
Name _...
Address(if different from location)
Cityfrown state Zip Code
r.
Telephone umber � d
i;
B. Pumpingj poor
tY p Gallons
1. Date of Pumping 2-Quantity Pumped: --��
Date
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 ❑ No
6. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
G L S. " Lowell Waste Water
.,� + r ..
Sign a Flaule Date F
t5form4.doc•06/03 system Pumping Record-Page 1 of 1