HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 86 FULLER ROAD 6/24/2021 : Commonwealth of Massachusetts RECEIVED
= City/Town of JUN 2 4 701'
System Pumping Record
Form 4 TOWN OF NOW h-�^IUU,/ER
HEALTH OEFART IIENT
DEP has provided this form for usezby 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 'ght front of house Left/Right rear of house, Left/right side of house, Left
Right side of building, L ight 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 State- Zip Cpdde
�-�`/— ��' c� ,mil
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 0-S'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: I
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wire contents-were disposed:
Lowell Waste Water
SignAtute fHaul Date
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