HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 FULLER ROAD 5/17/2021 Commonwealth of Massachusetts RECEIVED
. City/Town of MAY 17 2021
System Pumping Record T CfIh KTHAN00VER
Form 4 H TH DpARYMEW
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 t front of house a Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rig i ron of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2 System Owner.
� 1h
Name
Address(if different from location)
CitylTown State r r Zip e
Telephone Number
.B. Pumping Record
1. Date of Pumping pate 2- Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �Jy � ('1 �✓�� ,��_�����
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo n ere contents-were disposed:
Lowell Waste Water
Signitule 9t Haul Date
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