HomeMy WebLinkAboutSeptic Pumping Slip - 131 GRANVILLE LANE 7/31/2017Commonwealth of Massachusetts
City/Town of . '
System Pumping. Record
Form 4
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 submittedto
the local Board of Health or other approving authority.
•
. A. Facility. Information
1. System Location: Left / Right front of house, LefttfITO rear. o ou . ,Left/ right side of house, Left
Right side of building, Left / Right front of building, left / Right rear 6 building, Under deck
Address
City/Town
2. System Owner.
Name.
State Zip Code
Address (if different from location)
City/Town '
B. Pumping Record
'!. Date of Pumping
a_ to -
Date`
State Ziiipj Code
L 1 V
Telephone Number
Quantity Pumped:
Gallons
3. Type•of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe): %
4. Effluent Tee Filter present? ❑ Yes
" 5. Condition of System:
6: System Pumped By:
Neil. Bateson.
• Name
Bateson Enterprises Inc
If yes, was it cleaned? ❑ Yes 0 No,
.XIll:-L ‘c. 1-f
Company
7. Lo -in here contents were disposed:
G t S:
F5821
Vehicle License Number
Sign e • Hauled / - Date
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