HomeMy WebLinkAboutSeptic Pumping Slip - 110 FULLER ROAD 10/15/2015 Commonwealth of Massachusetts
_ City/Town of .
ytem Pumping Record
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 Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left ig�i'Irear of haws , Left/right side of house, Left/
Right side of building, Left/Right front of building, a ear of building, Under deck
Address
. �,
City[Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State Zip C de ;
Telephone Number
t
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: gallons y�
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ 146 _ If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste
A
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio w ere contents were disposed:
Lowell Waste Water
Sign a cf Haule Date
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