HomeMy WebLinkAboutSeptic Pumping Slip - 42 FULLER ROAD 11/7/2016 Commonwealth of Massachusetts
RECEIVED
u City/Town of
System Plumping,Record NOV 1 ,
Form 4
DEP has provided this form for us&by local Boards of Health. Other forms maybe 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 ' �, ighfj c— of 17ouse`�Left/Right rear of house, Left/right side of house, Left/
0 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 Co
F
Telephone Number
a
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons ,
3, Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®-'90, If yes, was It cleaned? ❑ Yes ❑ No,
` 5. Condition of System
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo an- -here contents were disposed:
G L S: Lowell Waste Water
Sign a 4 HbuleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1