HomeMy WebLinkAboutSeptic Pumping Slip - 80 SUTTON HILL ROAD 5/1/2017Commonwealth of Massachusetts
City/Town of
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DEPART MENT
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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'
checkwith your
local Board of Health to determinethe form they use. The System Pumping Record mustbe submitteclto
the local Board of Health or other approving authority.
A. Facility Infor
afln
1. System Location: Left / Right front of house, Righ
Right side of building, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
city/rown
2. System Owner:
Name
Address (if different from locat on)
State
1A-162-4
Left/ right side of house, Left /
Zip Coda
City/Town
Pu
I
1. Date of Pumping
Date
3. Type of system 0 Cesspool(s)
Ej Other (describe):
State
Telephone Number
2. Quart 'ty Pumped:
Gallons
ptic Tank ID Tight Tank
4. Effluent Tee Filter present? El Yes
" 5. Condition of System.
y
, was it cleaned? El Yes El No,
6. System Pumped By:
Neil. Batesbq
Name
Bateson Enterprises Inc.
Company
7. Loca.yn4ro contents were disposed:
owell Waste Wat
F5821
Vehicle License Number
t5forrn4.doc6 OB/03
System Pumping Record 6 Page 1 of 1