HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 4/9/2021 Commonwealth of Massachusetts
_ City/Town of APR o D 2021
System Pumping Record
Form 4
r•
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: Lgii f2ioa front of hous i' eft/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)
City/Town Stater � L k� Zin Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) U Se�iic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes OlmO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L UHauiwu
Lowell Waste Water
Sign Date
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