HomeMy WebLinkAboutSeptic Pumping Slip - 171 LIBERTY STREET 12/13/2016 Commonwealth of Massachusetts
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City/T own of RECEIVED
S 'S tem Pumping.Record 9 2016
Form 4
TQ M1,IquE d"40R1 BAV'T>OVER
by p Other
iin orrmation-must be substantial) the tame as that provided here. Before usin .th s 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. Inform' ation
1. System Location: Left/Right front of Mouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, .eft/Right rear of building, Under deck
Address l
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town - State Zlp d _
Telephone Number ��y
j
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: canons
3. Type-of system: ❑ Cesspool(s) [D -Septic Tank 0 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 0 If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
w
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc,
Company
7. Lo ca' ri,�Kl ere contents were disposed:
G L� Lowed Waste Water
SigZe Hiule Date
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