HomeMy WebLinkAboutSeptic Pumping Slip - 7 FULLER MEADOW ROAD 10/26/2016 Commonwealth of Massachusetts
_ City/Town of .
S
Rec
ystem Pump"rng-Record
Form 4 OC„I j
DE has provided this form for use=by local Boards of Health. other forms may be to ,'Check 00but the
information must be substantially the same as that provided here. Before using.this 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 L ijkfront of houwe Left 1 Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
...........
Citylrown State zip Code
2. System Owner:
Name.
Address(if different from location)
city/Town - State Zip d
Telephone Number
.B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system, ❑ Cesspool(s) ❑- pt cl Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®--No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6.. System Pumped By:
Neil.Bates ri F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati n wwhere contents-were disposed:
C• Q Lowell Waste Water
LJVrojWk_),,��.� 4r
SignAtufa, Haule Date
06=4.doc•06/03 System Pumping Record•Page 1 of 1
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