HomeMy WebLinkAboutSeptic Pumping Slip - 103 FULLER ROAD 3/15/2017Commonwealth of Massachuse
City/Town of .
te u ecor
11'
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DEP has provided this form. for us&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
for
1. System Location: Left / 1jht frontothou , Left / Right rear of house, Left/ 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:
Narrie'
Address (if diffennt from location)
State
City/Town '
co
. Date of Pumping
Date
3. Typeof system 11 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? Ej Ye
' 5. Condition of System:
Telephone Number
2. Quantity Pumped:
Zip Code
Gallons
ptic Tank 0 Tight Tank
If yes, was it cleaned? EJ Yes 0 No,
6: System Pumped By:
Neil. Batesbri
' Name
Bateson Enterprises Inc
Company
7. Locati n-ii,er contents were disposed:
owell West
F5821
Vehicle License Number
Sign e Haute Date
t5fomn4.doc. 06/03 System Pumping Record Page 1 of 1