HomeMy WebLinkAboutSeptic Pumping Slip - 815 JOHNSON STREET 4/7/2016 Commonwealth of Massachusetts
City/Town of „�C,� ;,,. r��� �„ ,
System Pumping ar
Fora 4 : (.S '1.�: 'V'
A,
DEP has provided this form for use by local Boards of Health. Other forms ay° o( ".,I I xri, 7.
information must be substantially the same as that provided here. Before u � �c,�rlith' ur
local Board of Health tQ 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 Le side of_ .___....... ,
y � of house ': n -Qf bouse, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address �\
- ----- - - ----- -- --.
City/Town State Zip Code
2. System Owner:
- --------------
Name _
-- -----
- - - -- ----------------- -- ----
Address(if different from location)
-- -- ry
- ----
City/Town - State .� 1. Zips Code
Telephone Number
B. Pumping ec rd
1. Date of Pumping - - — 2. Quantity Pumped: - -- -
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑°'optic Tank-`' ❑ Tight Tank
❑ Other(describe): -- -- ----
4. Effluent Tee Filter present? ❑ Yes 0-'lo If yes, was it cleaned? ❑ Yes ❑ No
5. Condi io of System: f'
-----------------------
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
------- ----
Company --- —
7. Loca ion.,wrhere contents were disposed:
G.L.S. we I aste Water
Signatu u Date =' -
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
TOWN OF
'Ll1j,
SYSTEM PUMPING RECORD
DATE:—S lz
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example:left front of house)
<� c, kv'L ) VA
DATE OITPUMPING: I QUANTITY PUMPED : e GALLONS
CESSPOOL: NO '-/ - YES NEPTIC TANK: NO YES v
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHITIELD RUNBACK
EXCESSIVE El SOLIDS FLOODED
SOLIDS CARRYOVE R OTHER(EXPLAIN)
SYSTEM PUMIE D BY: at son Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: