HomeMy WebLinkAboutSeptic Pumping Slip - 26 EASY STREET 5/1/2017 Commonwealth of Massachusetts !!,,CO3VED
City/Town od
tem Pumpift.Recordv
Form 4
DEP has provided this form for use-by local Boards 6 Health. Other forms may be'used,but the
information must be substantially the game as that provided here. Before using.this form,check with your
local Board of Health to determine the forrb they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
t. System Location: Left It front of house,L.eftI Right rear of house, Left/right side of house, Left/
tui( Dight side of building, Left°T tg ron o uildifig, Left/Right rear of building, Under deck
Address
Cityrrr, ,n _ State Zip Code
Z System Owner:
Marne'.
Address(if different from location)
City/Town tate/�`n �, Zi (_
"telephone Number
I
• Y
Pqm:ping Kocord
I. Date of pumping tate . Quantity Pumped:
Gallons
. Type-of system: Cesspool(s) eptic Tank El Tight Tank
Other(describe): ---4. Effluent Tee Filter present? E] `Yep o If yes,�was �cleaned? Yes No,
5. Condition ofSystem: V\-
6.-
6: System Pumped 6y:
Pfeil.Sat bn - F'5821
Name vehicle License Number
Bateson Enterprises Inc,
Company
T. Lo '� h contents were disposed:
Lowed Waste dater
Sign a Haule a Cate F
t5fbrm4.doc-08/03 system Pumping Record m rage 1 of 1