HomeMy WebLinkAboutSeptic Pumping Slip - 922 DALE STREET 5/1/2017Commonwealth of Massachusetts
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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 Info
11 "
at
•
I. System Location: Left / Right front of house, Left / Right rear of housc0=efii-rightle of housejeft /
Right side of building, Left / Right front of building, Left / Right rear of building, Under—dedc
2. System Owner:
Name'
Address (if different from location)
City/Town
Stat
Telephone Number
Pppang ec
I. Date of Pumping
Date
2. Quan5 Pumped:
Gallons
3. Type.of system 0• Cesspool(s) eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? E] Yet LT
5 Condition of System: *
If yes, was it cleaned? 0 Yes El No,
6. System Pumped By:
Neil, Bateson •
Name
Bateson Enterprises Inc
Company
7. Location re contents were disposed:
o eil Waste Wa
Sign
F5821
Vehicle License Number
Da
1
t5form4.doc• 06103
System Pumping Record Page 1 of 1