HomeMy WebLinkAboutSeptic Pumping Slip - 86 FULLER ROAD 9/23/2015 I,ff
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Commonwealth of Massachusetts
= v City/Town of .
Y� tem Pumping. rd
Form 4
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 Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left fight,'frontµ' house;'JLeft/Right rear of house, Left/right side of house, Left/
Right side of building, Left%Right frontof�uilditig, Left/Right rear of building, Under deck
Address
CityfTown State Zip Code
2. System Owner E C Ell l d"
ISEF
Name
Ovl,f U II�
Address(if different from location) t J H UL 17'71 7� l
Cityfrown slake? a~t ;
Telephone Number Y
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B. Pumping Record
[1-2
1. Date of Pumping Date 2. !Quaptity Pumped: Gallons
3. Type,of system: ❑ Cesspool(s) 13—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3`4o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem 'cz
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc-
Company
7. Locatio whgre contents were disposed:
L S. Lowell Waste Water
Sign a I Haule Date
t5form4.doe•06/03 System Pumping Record•Page 1 of 1
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