HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 FULLER ROAD 11/12/2019 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record NOV � 2 2019
Form 4 TOWN OF N[)gPR MpEt�VTER
HEATH
DEP has provided this form for use by local Boards of Health. Other forms may be 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 Location: Left/Right front of house, Left/ tah rear of housa; Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town l l�CJ State Zip Coda
2. System Owner.
Name
Address(i different from location)
CttylTown S12* p Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Dam I Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) p"c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9_K0 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle Ltcense Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
S Lowell Waste Water
Sign aobuiev Date
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