HomeMy WebLinkAboutSeptic Pumping Slip - 177 CARLTON LANE 5/1/2017Co: .'1.'nionwealth of Massachusetts
Cty/Tow ofPr'GriVED
y tem Pu p ecord
For 4 vAcgcl t,,,movoI•
• Ob„,A
DEP has provided this form for useby 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 four' they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. A. Facility Informatiora
1. System Location: Left / Right front of house, Left / Right rear of house, Left ijside of housLeft /
Right side of building, Left / Right front of buildirig, Left / Right rear Of building, Undtt
er ep
2. System Owner:
Address (if different from location)
City/Town
Stet
Telephone Number
441
P
11
p
te o d
2. Quantity Pumped:
Date Gallons
3. Type of system 0 Cesspool(s) S—Sel-Tank 0 Tight Tank
Other (describe):
1. Date of Pumping
4: Effluent Tee Filter present? 0 Yes
. Condition of System:
If yes, was it cleaned? 0 Yes El No,
6. System Pumped By:
Nell. Bateson •
Name
Bateson Enterprises Inc
Company
7. Loca o contents were disposed:
owell Waste Water
F5821
Vehicle License Number
t5forrn4.doc. 0S/03
System Pumping Record Page 1 of 1