HomeMy WebLinkAboutSeptic Pumping Slip - 51 HAY MEADOW ROAD 5/15/2017Commonwealth of Massachusetts
City/Tow of
yste Pu pinecsr
F
DEP has provided this form. for useAv 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.
A. Facility I
for
1 1
atiora
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
City/Town
2. System Owner:
Name*
Address (if different from locatio
City/Town
Telephone Number
PL
g Ft!‘c
1. Date of Pumping
. Type of system':
0 Other (describe):
Date
Cesspool(s)
4. Effluent Tee Filter present?
5. Conditiorlystern:
0 cA-k
1
(
2. Quantity Pumped:
Gallons
optic Tank 0 Tight Tank
No If yes, was it cleaned?
No
6: System Pumped By:
Neil Batesbn
' Name
Bateson Enterprises Inc
Company
7. Lo contents were disposed:
owell Waste Water
Sr
F5821
Vehicle License Number
t5form4.doo* 06/03 System Pumping Record ®"Page 1 of 1