HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 4/23/2020 : Commonwealth of Massachusetts E D
City/Town of APR 9 2020
System Pumping Record TOM OF NOR111AMXMM
Form 4 tH DE 'T
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 Locatio eft ron of house'
/Right rear of house, Left/right side of house, Left!
Right side of bulgy ing, Left/Right ront of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town St -) �'' ` °,7�zt
Telephone Number
B. Pumping record
1. Date of Pumping r�3 -25
Date 2. Quantity Pumped: ns
3. Type-of system: ❑ Cesspool(s) [-SepClc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition f System:
6. System Pumped By-
Neil.Batesbn _ F5821
Name
Bat Vehicle Ltoense Number
_ eson Enterprises Inc
Company
7. 7Lola, w re contentswere disposed:
L S j Lowell Waste Water
sign1we fllallwuDate
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