HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 7 FULLER MEADOW ROAD 4/1/2020 .� Commonwealth of Massachusetts RZ�Z1Ve0
MINNOMCity/Town of APR
System Pumping Record TOWOFNO � Zo2o
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Form 4 NZACTyPTHANDp,�c�
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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: Le i Qt of�hou , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CilyfTOwn Tip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date �eptic
roped: Gallons
3. Type of system: ❑ Cesspool(s) nk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0140 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.-
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' e contents were disposed:
�L S Lowell Waste Water
qyrj- I - —3c'--a7v
Signitufs cfHaulerUDate
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