HomeMy WebLinkAboutSeptic Pumping Slip - 600 FOSTER STREET 3/10/2017Commonwealth of Massachusetts
City/Town of
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DEP has provided this form. for usem local Boards Of Health. Other forms thayibe'Llsed,, but the
information must be substantially the same as that provided here. Before usingihis 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 11 forme°
fr--) 1. System Location: Left / Right front of house, Left / ighttear of house? Left / right side of house, Left /
Right side of building, Left / Right front of buildirig, Left / Right rear Of building, Under deck
2. System Owner:
Narne'
Address (if different from ocaflon)
City/Town
1. Date of Pumping
Date
Stair'"? (-7. 1. tSC
- , -Zip Code
Telephone Number
2. Quantity Pumped: Gallons
3. Type•of system: El Cesspool(s) eptic Tank El Tight Tank
0 Other (describe):
4. Effluent Tee Filter present?
5 Condition of System:
6. System Pumped By:
Neil Bate -Son
Name
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
owell Waste Wat
iont e • Haule
If yes, was it cleaned? Ea-ns
F5821
Vehicle Li
Da
nse Number
t5form4.doc® 06103 System Pumping Record Page 1 of 1