HomeMy WebLinkAboutMiscellaneous - 20 FULLER MEADOW ROAD 4/30/2018 (2) 20 FULLER MEADOW ROAD
210/104.D-0125-0000.0
Commonwealth of Massachusetts
N City/Town of
a
W° System Pumping Record
Form 4 NOV " to t0
M
DEP has provided this form for use by local Boards of Health. 0th rfteu ed but he
information must be substantially the same as that provided here. k with your
local Board of Health to determine the form they use. The System ubmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City(Town Stat Q�� � Z-�e
Telephone Number
B. Pumping Record
tL-1 ccs l�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
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
5. Conditionc)
System: IVnI�
6. System Pumped By: _
Name Vehicle License Number
Company
7. �Loati re contents were disposed:
S.D. Lowell Waste W r
SignatVoler Date
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