HomeMy WebLinkAboutSeptic Pumping Slip - 75 WINDKIST FARM ROAD 3/10/2017Co monwealth of Massachusetts
City/Tow
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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 Infor atio
1. System Location: Left / Right front of house, Left / RightraersithouseXeft/ right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2. System Owner:
Name
State
Zip Code
Address (if different from location)
City/Town
Pu
g Rpc
Date of Pumping
Type -of system':
0 Other (describe):
Date
Cesspool(s)
2. Quantity Pumped:
eptiCfk 0 Tight Tank
r
4. Effluent Tee Filter present? 0 Ye s 0--No
Condition of System:
6: System Pumped By:
Neil. Bateson
• Name
Bateson Enterprises Inc
Company
7. Locati
Sign
contents were disposed:
oweil Waste Water
If yes, was it cleaned? 0 Yes 0 No
F5821
Vehicle Lkense Number
Date
t5form4.doc. 06/03 System Pumping Record 0 Page 1 of 1