HomeMy WebLinkAboutSeptic Pumping Slip - 506 BOSTON STREET 11/18/2014 Commonwealth
µ
City/Town of
S 'tem Pumping Record
YS
Form - �,
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 ,�L;7�1 Nigh QRirear Left/right side of house, Left Right side of building, Left/Right front of bung, Left of building, Under deck
Address
City/Town Mete _ Zip Cade
2. System Owner:
Flame
Address(if different from location)
City/Town Mete ip d
Telephone Plumber
B. Pumping Record >
1. Date of Pumping 2. Ouhn ity Pumped:
Cate Gallons
3. Type of system: Cesspool(s) Septic lank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? D-Ye-j El No If yes, was it cleaned? os No,
5. Conditio of SSystem:
6. System Pumped By:
Nell Bates®n F5821
Name Vehicle License Plumber
6ateson Enterprises Inc
Company
7. Lo ti pre contents were disposed:
XteLowell Waste Water
�ule Tate
t5form4.doc-06103 System Pumping record«Page 1 of 1