HomeMy WebLinkAboutSeptic Pumping Slip - 101 COLONIAL AVENUE 8/21/2017 Commonwealth of Massachusetts ID
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SOtem Pumping.Record
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DEP has provided this form for use-by local Boards of Health. Other forms may be used, �uf the
information,must be substantially the tame 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 Informi ation
1. System Location: Left i Right front of Mouse, Left 1 Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
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Address
City/Town State Zip Code
2. System Owner:
1
Name'
Address(if different from location)
CityfTown Stater de
Telephone Number
• i;r f
.B. Pumping record _
1. Cate of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) pti Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes 0 o If yes, was 3t cleaned? MYes F1 No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company {
7. Locauo " e onterrt Were disposed:
Q, L S: Lowen Waste Water
Sign a Houle Date f
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