HomeMy WebLinkAboutSeptic Pumping Slip - 327 SALEM STREET 5/15/2017Commonwealth of Massachusetts
City/Town of
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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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
• A. Facility Inform to • n
1. System Location: Left / Right front of house, Left / Right rear of house, Left / ht side of house_t_e /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
City/Town
2, System Owner:
Name*
Address (if different from location
City/Town
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1. Date of Pumping
Date
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3. Type of system': Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
5. Condition of Systern:,
6: System Pumped By:
Nell Bateson
' Name
Bateson Enterprises Inc
Company
contents were disposed:
owell Waste Water
Sign
Telephone Number
2. Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
Date
t5form4.doc® OS/03 System Pumping Record Page 1 of 1