HomeMy WebLinkAbout- Septic Pumping Slip - 55 FULLER ROAD 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumpling Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe'used,but the
information,must be substintially the tame 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 Location: Left/Right front of house eft Rlgh tjg��, Left/right side of house, Left I
Right side of building, Left/Right front of budilhgal, Left/Right rear of building, Under deck
Address
,55 -k--j V��
—citif—rown state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown Stater Zip Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Qu6nfity Pumped: Gallons
3. Type-of system: Ej Cesspool(s) &-geptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes �0 If yes, was it cleaned? Ej Yes ® fro
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
................
Company
7. Location where contents-were disposed:
G,L—. Lowell Waste Water
Sign e Mw Date
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