HomeMy WebLinkAboutSeptic Pumping Slip - 103 FULLER ROAD 5/1/2018 Commonwepith of Massachuseffs
Citk/Town of 110 0 12'0 18
®EP has Provided this foram far use-by local Swards of Health. Other forms may be'used, but the
information•must be substantially the#ame as that provided here. Before using.this farm,check with your
local Board of Health to determine the forret they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. cfl In ti
Right side of building, Left/R'i h f a4s-e, Left/Right rear of house, Left/right side of house, Left/
1. stem Location: Left i t f � �._.
of building, Left/Might rear of b ilding, Under deck
Address
city/Town State Zip code
2. System Owner:
Name'
Address(if different from locafian)
' cityTrown •. Stag f �� -- p�" � -�' .'
fl Telephone Number `
pyn@ Rgeord
1. Cate of Pumping Date 2. Quantity Pumped:
Gallons ,
3. Type-of system: E Cesspool(s) eptic Tank D Tight Tank �.
El Other(describe):
4. Effluent Tee Filter present? Yep a if yes, was it cleaned? 0 Yes ® No,
5. Condition of System: •---1,�../�.-��' ",�'�/ ',-� � _��C.m � :_._.
6. System Pumped By:
!dell.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc'
Company
7. Locati ere contents were disposed:
too
Lowell Waste Water
Signul Date
tMrm4.doc-06103 System Pumping Record Page 1 of 1