HomeMy WebLinkAboutSeptic Pumping Slip - 104 SHERWOOD DRIVE 3/10/2017If yes, was it cleaned? rj Yes 0 No,
F5821
Vehicle License Number
Commonwealth of Massachusetts
• City/Tow of
yste u g &cord
For
4
(.)
"IOVVN OF rCk." ANDov
HEAL„TH DEPARI" tviEIT
DEP has provided this form for usaby 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, !rotor atiol
1. System Location: Le Right front of house eft/ Right rear of house, Left/ right side of house, Left /
Right side of building, e uildirig, Left / Right rear of building, Under deck
Address
City/Town
to c4
2. System Owner:
Address (if different from location)
State
City/Town
P
g Reco
1 Date of Pumping
Date
Typaof system': 0 Cesspool(s)
ID Other (describe):
4. Effluent Tee Filter present? El Ye,
" 5. Condition of System:
6: System Pumped By:
Neil Bates -on,
• Name
Bateson Enterprises Inc.
Company
•
T&ephone Number
4-72. Quantly Pumped:
Zip Code
Gallons
ptic Tank 0 Tight Tank
7. Lo tionwhere contents were disposed:
owell Waste Water
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