HomeMy WebLinkAboutSeptic Pumping Slip - 981 JOHNSON STREET 6/1/2017Commonwealth of Massachusetts
City/Town of
ystern P p Record
Fo
DEP has provided this form. for use=by local Boards Of Health. Other forrn°s\N"tmU'lauLyuP‘sikedt4t:Lt the
information must be substantially the same as that provided here. Before using.this forrn, 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 Info
tit),
1. System Location: Left / Right front of house, Left / Right rear of house, Left gIticfeofhoeLeft /
Right side of building, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
bt-tY/Town
t
2. System Owner:
Name
Address (if different from I ion)
City/Town
Pt
gRe
1. Date of Pumping
Date
3. Type of system': 1:1 Cesspool(s)
0 Other (describe):
4. Effluent Tee Filter present? El Ye,
" 5. Condition of §"ystern:
Telephone Number
2. Quantity Pumped:
Gallons
Tank 0 Tight Tank.
If yes, was it cleaned? EJ Yes E] No,
6: System Pumped By:
Neil. Bates -on
' Name
Bateson Enterprises Inc
Company
7. Loconher contents were disposed:
owell Waste Water
F5821
Vehicle License Number
t5form4.doc, 06/03
System Pumping Record Page 1 of 1