HomeMy WebLinkAboutSeptic Pumping Slip - 102 LOST POND LANE 6/5/2017Commonwealth of Massachusetts
City/Town of
yste Pu pirs0 ecor
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DEP has provided this form for use.by 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 submitteFito
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left / Right rear of houseaOrigh idt'ir.e)nouse)Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Undirde
Address
City/Town
2. System Owner
Address (if differentrom location)
City/Town
Pui
gRe
1. Date of Pumping Date
3. Typeof system: Ej Cesspool(s)
1:3 Other (describe):
• 4Effluent Tee Filter present? 0 Yes
' 5. Condition of ys em:
6; System Pumped By:
Neil Bateson
• Name
Bateson Enterprises Inc
Company
7. Locati. here contents were disposed:
owell Waste Wat
Skrn e Haule
Stater-\
Telephone Number
2. Quantity Pumped:
ptic Tank
Gallons
E) Tight Tank
If yes, was it cleaned? 0 Yes EJ No,
F5821
Vehicle License Number
Date
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