HomeMy WebLinkAboutSeptic Pumping Slip - 1641 SALEM STREET 11/16/2017 . Commonwealth of Massachusetts
RECEIVED
_ C4/Town of t 18
w° S item Pumping.Record
...
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i
K-AForm 4 i c M J
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DEP has provided this farm for ease=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 farm they use.The System Pumping Record must be submitted tee
the local Board of Health or other approving authority.
A. Facility inform' ation
I. System Location: Left/Right front of Mouse, Left/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
Address
CWrown State - Zip Code
2. System Owner:
Name' j
Address(if different from location) !
f
Cityfrown State- Zip Code ;
Telephone Number ✓`''�
. Pumping JRecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) [3—Sp Ic Tank [] Tight Tank i
El Other(describe):
4. Effluent Tee Filter present? [I Yes o if yes, was it cleaned? E Yes El No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson ' F5821 f
Name Vehicle License Number
Bateson Enterprises Inc.
Company t
7. LocationyMpre contents-were disposed:
CLS: Lowen Waste Water
SignAWe I Hauie Date
0orrn4.doc>06/03 System Pumping Record•Page 1 of 1