HomeMy WebLinkAboutSeptic Pumping Slip - 155 DUNCAN DRIVE 5/24/2017Commonwealth of Massachuse
City/Town of • •
yete P ping•Recor
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DEP has provided this form for us&by le 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 yo
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.
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1. System Location: Left / Right front of house, Left / Right rear of house, Left. ri deg Ir-Tc-I-1----ouse' Left /
Right side of building, Left / Right front of building, Left / Right rear of building,
2. System Owner:
Name
Address (if different from loc )
City/Town '
P
Telephone Number
P g Ft
. Date of Pumping
. Type of system':
c
Other (describe):
4. Effluent Tee Filter present? 0 Ye
Date
Cesspoot(s)
" 5. Condition of Syste
XLJ
2. Quantity Pumped:
ticTank 0 Tight Tank
If yes, was it cleaned? 0 Yes
\
6: System Pumped By:
Nell Bates"on
Name
Bateson Enterprises Inc
Company
7. Lo
where contents were disposed:
Haul
owell Waste Water
F5821
Vehicle License Number
Date
15form4.doc. 06/03 System Pumping Record Page 1 of 1