HomeMy WebLinkAboutSeptic Pumping Slip - 75 LOST POND LANE 10/16/2017DEP has provided this form' for ussby local Boards Of Health. Other forms rnT°aVCI-(reiT'Fise:
CdIl-PP,
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 submitted to
the local Board of Health or other approving authority.
Commonwealth of Massachusefts
City/Town of •
System Pumping.Record
Form 4
A. Facility Information
1. System Location'
Right side of building, Left / Rig
of hous , Left / Right rear of house, Left/ right side of house, Left /
tongof buildirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
MS
State Zip Code
Name'
Address (if different from location)
City/Town
Telephone Number
B. Pumping Record
1 Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Typeof system': Cesspool(s) ID—StsPtic Tank Ej Tight Tank
E] Other (describe):
4. Effluent Tee Filter present? Yes a-446' If yes, was it cleaned? Ej Yes Ej No,
5. Condition of System:
1'
6: System Pumped By:
Neil Bates -on
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
°well Waste Water
Sign e Haute
F5821
Vehicle License Number
t5form4.doc• 06/03
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