HomeMy WebLinkAboutSeptic Pumping Slip - 217 GRAY STREET 5/24/2017ip
Commonwealth of Massachuse
City/Town of
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TOWN NUK ij H AN uOVER
HEALTH DEPARTMENT
DEP has provided this form for uset,y 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 informatio
1. System Locatio e / Rgif6nt of house, Left/ Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right Font of building, Left / Right rear of building, Under deck
Address
2. System Owner:
Nrn
Address (if different m location)
City/Town •
p
1
Reco
1. Date of Pumping
Date
3. Type of system': 0 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present?
Condition of System:
6: System Pumped By:
Neil. Bates -on
' Name
Bateson Enterprises Inc.
Company
7. Location w
t)
Zip Code
Telephone Number
2. Quanti Pu ped:
Gallons
eptic Tank 0 Tight Tank
-re contents were disposed:
No If yes, was it cleaned?
owell Waste Water
F5821
Ili V
No
Vehicle License Number
Date
t5fonn4.doc. 06/03 System Pumping Record Page 1 of 1