HomeMy WebLinkAboutSeptic Pumping Slip - 458 FOSTER STREET 6/1/2017Commonwealth of Massachusetts
City/Town of
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DEP has provided this form for use,by local oards 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 informatiop
1. System Location: Left / ght1bnt of house Left / Right rear of house, Left / right side of house, Left /
Right side of building, Le g t fron of building, Left / Right rear of building, Under deck
CA4
City/Town
2. System Owner:
State
Zip Code
Address (ifdifferent from location)
City/Town
g
1. Date of Pumping
3. Type of system':
Other (describe):
Date
Cesspool(s)
2. Quantity Pumped:
Gallons
- •
Tank
Tight Tank
4. Effluent Tee Filter present? 0 Yes
. Condition of Syten:
If yes, was it cleaned? 0 Yes LJ Na
6: System Pumped By:
Nell Bates -or!
' Name
Bateson Enterprises Inc
Company
7. Loca or here contentswere disposed:
owell Waste Water
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record Page 1 of 1