HomeMy WebLinkAboutSeptic Pumping Slip - 55 FULLER ROAD 12/17/2015 Commonwealth of Massachusetts
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City/Town of
YS
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 hour�IFL�e
Righf�rea�� ,u s�, Left/right side of house, Left/
Right side of building, Left/Right front of birig, Left/Right rear of building, Under deck
• Address
4.,,
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown State Code
Telephone Number 7-:',
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B. Pumping record .
1. Date of Pumping Date 2• Quantity Pumped:
Gallons r
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p El Yep o If yes, was it cleaned? ED Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
Lowell Waste Water
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Sign a 9t HaulerU Date
0orm4.doc•06/03 System Pumping Record•Page 1 of 1