HomeMy WebLinkAboutSeptic Pumping Slip - 71 WINTERGREEN DRIVE 5/24/2017F5821
Vehicle License Number
Commonwealth of Maisachusett CE E
City/Town of •
yste P11 p ecor
Fo 4
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, 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 Infor
I 1
atiop
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
Cfty/Town
2. System Owner:
Address (if different from location)
City/Town
PLI
131
d
1. Date of Pumping
Date
3. Type of system 0 Cesspool(s)
D Other (describe):
MAY 2 4 2011
TOWN OF NOR HANDOVER
HEALTH DEPARTMENT
Telephone Number
2. Quantity Pumped:
eptic Tank 0 Tight Tank
[E-------
4. Effluent Tee Filter present? Ci Yes rNo If yes, was it cleaned? 0 Yes 0 No,
5. Condition of Sy
6: System Pumped By:
Neit Batesdn
Name
Bateson Enterprises Inc
Company
7. Lgpatknihere contents were disposed:
owell Waste Wa e
t5form4.doc. 06/03 System Pumping Record Page 1 of 1