HomeMy WebLinkAboutSeptic Pumping Slip - 465 CHESTNUT STREET 5/1/2017Corn onwea
City/Tow of
ystem Pum
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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 forrn, 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.
1
h of Massachusetts
rn
ecord
A. Facill,ty nfor aton
1. System Location: Left / Right front of house, 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
2. System Owner:
Address (if difterent from lo
City/Town
1. Date of Pumping
3. Type of system':
er (describe):
Sta
7
Zip Code
Telephone NumbDr
r7
2. Quantity Pumped:
Cesspool(s) 0 Septic Tank
4. Effluent Tee Filter present? 0 Yes 0 No
5 Condition of System:
If yes, was it cleaned? 0 Yes 0 No,
6: System Pumped By:
Nell. Bateson
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
owell Waste Wat
Sign H ui
F5821
Vehicle License Number
Date
t5forrn4.doc. 06103 System Pumping Record 0 Page 1 of 1