HomeMy WebLinkAboutSeptic Pumping Slip - 154 ROCKY BROOK ROAD 1/17/2017 Commonwe-alth of Massachusetts
City/Town of
Pumping, JAN "°
Form 4
®EP has provided this ford for use-by local Boards of Health. Other forts may be'used, but the 1
information-must be substantially the same as that provided here. Before using.this form,check with your I
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted fc)
the local Board of Health or other approving authority.
•
A.
ciQity
8n or ti n
t. System Location: Left/Right front of Mouse, Left(
�Rki6fiiy g rear of ouLeft/right side of house, Left f
Ri ht side of building, Left/Right front of buildin M Mrear of building, Under deck
. ,address .
- `
cityfrown State dip Code
2, System Owner:
vvk `Gi,
Name`
Address(if different from location)
cityrrown Mete• Zip Code
Telephone umber
® Pumping
1. Date of Pumping Date uantity Pumped: `-7
• Gallons
. Type-of system: E Cesspool(s) Septic Tank Tight Tank
El Other(describe):
4. Effluent"fee Filter present? {J Yep /Mo if yes, was it cleaned? Yes No,
6. Condition of.System:
6: System Pumped By:
Pfeil.Bat an F5821
Name Vehicle License Number
_Bateson Ehterprises Ino'
Company
7. L tion-where contents were disposed:
%LS, Lowe-If Waste Water
Sign Houle Q< '
t
t5fbrm4.doc-06/03 System Pumping Record Page I of 1