HomeMy WebLinkAboutSeptic Pumping Slip - 98 FULLER ROAD 5/15/2017Corn onwealth of Massachusetts
City/Town of
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DEP has provided this form for useby local Boards of Health. Other forms may be ik6d, but
the
information must be substantially the same as that provided here. Before using this forrn, 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 Inform -.Hon
1. System Location: gft%
Right side of building, Le
2. System Owner:
t of hai.s..e?Left/ Right rear of house, Left/ right side of house, Left /
of buildirig, Left / Right rear of building, Under deck
Address (if differentfrom location)
City/Town
1. Date of Pumping
3. Typeof system':
El Other (describe):
Date
Cesspool(s)
Telephone Number
2. Quantity Pumped:
lc Tank 0 Tight Tank
• 4. Effluent Tee Filter present? Ej `tre.
5. Condition of System:
6. System Pumped By:
Neil• Bateson
' Name
Bateson Enterprises Inc
Company
7. Locontents were disposed:
Lowell Waste Wate
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
t5form4.doc. 06/03
System Pumping Record Page 1 of 1