HomeMy WebLinkAboutSeptic Pumping Slip - 506 SALEM STREET 10/25/2017 Commonwealth of Massachusetts RECEIVED
w C4/Town of y4'
System Pumping.Record
T004 OF NORT14 AIJDOV
Form :ALTH C� �A:T�kLT
HE
DEP has Provided this formi 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, '
heck with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Informlation
1. System Location e Righ "o��fh—ous ,,)Left I Right rear of house, Left I right side of house, Left 1
Right side of bud Ing, Left/Rbuilding, Left/Right rear of building, Under deck
Address
Citylrown State - Zip Code
2. System owner
Name'
Address(if different from location)
r
f
Citylrown ` state• _ Zip Code
Telephone Number
:. t
. Pumping Record
—7
1. Date of PumpingDere 2. Quantity Pumped: N
Gallons
3. Type-of system. ❑ Cesspool(s) ank ® Tight Tank
® Other(describe):
4.. Effluent Tee Filter present? ❑ Ye.so if yes,was it cleaned? El Yes El Na
5. Condition of System:
V�- 4Z:7-(�,4
6. System Pumped By: t
Nell.Bateson ' F6821 {�
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo 'o hero contents were disposed:
L S: ` Lowen Waste Water
Sign a Haul, Date
Sform4,doc!06/08 system Pumping Record*Page 1 of 1