HomeMy WebLinkAboutSeptic Pumping Slip - 437 SALEM STREET 11/21/2017 Commonwealth of Massachusetts
i Y
CHWTown of -RECEIVED
4° S item Pumping.Record
Form 4•
DEP has provided this form for use-by local Boards of Health. Other f"b-YiiWbddiffd, 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.
A. Facfl%ty Information _ r
1. System Location: Left/Right front of douse « Ri9h ow , Left/right side of house, Left)'
Right side of building, Left/Right front of bur ing, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2, System Owner.
Name
Address(if different from location) 1
City/Town ' State Code
�7
Telephone Number
. Pumping Rpcor
..4
1. Bate of Pumpingbate �. Quantity Pumped: Gallons `
3. Type�of system: ® Cesspool(s) 0-5ptic Tank ❑ Tight Tank ;
® Other(describe):
=4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ® Yes ❑ No,
5. Condition of Syste � .Q • S �� ,
4 V C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle ticense Number
Bateson Enterprises Inc-
Company
nc Company
7. Locafi h re Contents-were disposed:
�,L Lowen Waste Water
f
OA
SignAqe qt Haute Date
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