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HomeMy WebLinkAboutSeptic Pumping Slip - 149 MARIAN DRIVE 10/4/2011 Commonwealth of Massachusetts _ City/Town of System In car Form 4 G AI SOYye DEP has provided this form for use by local Boards of Health. Other fo s may 6'e udec';Ibb the information must be substantially the same as that provided here. Befo usin this form h th your fitted to local Board of Health to determine the form they use. The System Pum , o the local Board of Health or other approving authority. '"' A. Facility Information 1. System,Loratj. n: Left front of house, right front of house, left side of house, right side of houses ei) L966f hour , ight rear of house, left side of building, right rear of building, under deck. Cityrrown State Zip Code 2. System Owner: ` Name - - Address(if different from location) City/Town State �� Z' Code , Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(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: 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enter rises Inc. _ Company 7. L oatiorr- here contents were disposed: G.L.S.D\. L II Wa r �....,,. Signature f u 1 Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1