HomeMy WebLinkAboutSeptic Pumping Slip - 83 LOST POND LANE 8/23/2011 <a\ Commonwealth of Massachusetts
City/Town of
u° System Pumping Record
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 front of hous ri ht fron , left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Andress(if different from location)
Citylrown State„ a l , -- Zip Cade
Telephone Number
B. Pumping Record
�C�GJ
1. Date of Pumping 2. Quantity Pumped.Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes UZNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ystem:
6. System Pumped By:
B Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
6--L.S. LAwell W t ater
r
Signature f a ler Date
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