HomeMy WebLinkAboutSeptic Pumping Slip - 300 FOSTER STREET 7/31/2017F5821
Vehicle License Number
Cornmonwepfth of Massachusetts
City/Town of .
•
System Pumpirig_Record
Form 4
DEP has provided this form for use.by local Boards Of Health. Other forms may be used, but the
informationmust 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.
)1 3 1 7.011
TOWN OF NORTH ANDO
HEALTH DEPARTMENT
. A. Facility. Information
1. System Location: Left ihtFojofhg� Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
City/Town
2. System Owner:
State Zip Code
Narne
Address different from location)
City/Town
State
Zip Code
Telephone Number
B. PumpingRecord
1. Date of Pumping D.2 I Quantity Pumped:
ate
3. Type -of system': 0 Cesspool(s) QJ Septic Tank El Tight Tank
Other (describe):
4. Effluent Tee Filter present? Yap 0 No If yes, was it cleaned? Yes El No,
" 5. Condition of System: c
6: System Pumped By:
Neil. BatesOn •
' Name
Bateson Enterprises Inc
Company
7. Locati.nhere contents were disposed:
owell Waste Water
F
Sign Haue ate
15form4.doc• 06/03 System Pumping Record • Page 1 of 1