HomeMy WebLinkAboutSeptic Pumping Slip - 96 FARNUM STREET 5/24/2017Commonwealth of Massachusetts
City/Town of
yste Pu pin -ecord
F 4
MAY 21 Z011
DEP has provided this form for use by local Boards of 1-rleT'O.F0
NtIOIRe'rolfoArNmD R
maybe used, but the
information must be substantially the same as that provided here. Before using.this forrn, check with your
t:TH DEPARTMENT
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 Information
1. System Location: Left / Right front of house, Left/ i h rear of ho Left / right side of house, Left /
Right side of building, Left / Right front of building, Left g rear c:4 building, Under deck
City/Town
2. System Owner:
State
Zip Code
Name
Address (if differentfrom lo o )
City/Town
g Re o d
1. Date of Pumping
Telephone Number
Date
3. Type of system: 0 Cesspool(s)
c:1 Other (describe):
4. Effluent Tee Filter present? Ell Yes
IZJ-
5. Conditir g./Sy6sAn j
2. Quantity Pumped:
eptic Tank Tight Tank
Gallons
If yes, was it cleaned? 0 Yes Ei No,
: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lo contents were disposed:
owell Waste Water
F5821
Vehicle License Number
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