HomeMy WebLinkAboutSeptic Pumping Slip - 42 FULLER ROAD 11/10/2015 Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4
DEP has provided this form for use=by local Boards of
ovide here. Before using.this form, check with your
information must be substantially the same as p
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 Right ront of house Left/Right rear of house, Left/right side of house, Left/
Right side of buil Id ng, Left/Right front of building, Left/Right rear of building, Under deck
Address f .
V` State Zip Code
City/Town
2. System Owner:
Name
Address(if different from location)
Stat Zip Code
city/rown �� ®�
j Telephone Number
it
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? Yes ❑ Na
" 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Vehicle License Number
Name
_Bateson Enterprises Inc'
company
7.iSign contents were di sposed:
. Lowell Waste Water
Haule Date
system Pumping Record•Page 9 of 1
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