HomeMy WebLinkAboutSeptic Pumping Slip - 79 ROCKY BROOK ROAD 6/1/2017 Commonwealth Massachusetts
RECEIVED
it�/Towno .
Sy6tem Pumping,Record
Form -H
TOWN 0,,ND,,A1T'MEN1
DEP has provided this forrrn for use-by local Boards oaf Health. Other forms may be'used, but the
information,must be substantially the tame as that provided here. Before using.this form,6
check with your
local Board of Health to determine the forrh they use. The System!Pumping Record mint be submitted to
the local ward of Health or other approving authority.
A. Facill.ty, Inform' ti
I. System Location: Left/Right front of house, Left/Hight rear orf hour. e 0 right1�a�f"house, m eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under_d-6q-i--- ,
Address ,
G a / '
ity/t own tat dip ode r
2. System Owner:
mama'
Address(if different from location)M
City/Town State Zip Code
Telephone Dumber ` t
, r
Pumping r
1. Date of Pumping gate � �� ` � . Quantity Pumped: �
Gallons
3. Type-of system: Cesspools) • Beptio Tank Tight Tank
Other(describe): - - ------
4. Effluent Tee 'Filter present? E] Yep No If yes, was it cleaned? El `fes 0 No,
' 5. Condition of System:
6: System Pumped By:
Dell.Bates7on F5821
Dame Vehicle License Plumber
Bateson Ehte rises Ino
Company
7. Location where contents were disposed:
t S: Lovell Waste Water
ry �
Sign a Houle mate
t5fdrrn4.doom 06/03 System lumping Record Page 9 of 1