HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 12/26/2017 1-7")
Commonwealth of Massachusetts
iW Town of .
r
`i�/St I� PCII"11pI Recon
N"hl_ 1..(I S L _a t``GI'4"f fFr l C
(Form 4
DEP has provided this form fox usemby local Boards of Health. Other form's maybe'used, 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. Facili_ty. Inform' ation
1. System Location: Loft/Right i joht c f house, ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/RIIg, on of buiidiri , Left/Right rear of building, Under deck
Address
Civ Town State Zip Code
2. System Owner: .
Name'
Address(if different from location)
cityrrown ' State 1 ,dip Cade
Telephone Number
f
a•
. Pumping.,Record
1. Date of PumpingDate 2. Quantity Pumped: 146
Gallons
3. Type-of system: ® Cesspool(s) eptie Tank El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? Yes ❑ No,
5. Condition of System: j
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc- J
Company
7. Locaton-• here contents-were disposed:
'C L MM3ul
Lowen Waste Water
Sign Date
t5f6rm4.doc^06/03 System Pumping Record.Page 1 of 1