HomeMy WebLinkAboutSeptic Pumping Slip - 116 SHERWOOD DRIVE 5/24/2017Commonwealth of Massachusetts
City/Town of
yste ping. Recor.
Fo 4
EC
4 2017
ENT.
•
DEP has provided this form for use:by local Boards o MWorms 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 for aton
1. System Location: Left / Right front of houspeitRiptfear ofL.,sa Left / right side of house, Left /
Right side of building, Left / Right front of b Let/ RighTFear of building, Under deck
2. System Owner:
Warne
dress (if differentfrom )
City/Town
State
TelephoneNumber
P p
11 I
g
ec
( 7
1. Date of Pumping 2. Quantity Pumped:
Date
Gallons
. Type of system 0 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
Condition of Sy stem:
6: System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
eptic Tank Ei Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
.
Company
7. caffb- contents were disposed:
G_L S..J. Lowel! Waste Water
Sign
Haule
F5821
Vehicle License Number
t5form4.doco 08/03 System Pumping Record Page 1 of 1