HomeMy WebLinkAboutMiscellaneous - 177 CARLTON LANE 4/30/2018•f,•�~ rII V ��
Commonwealth of Massachusetts
City/Town of "
S i tem Pumping - Rec rd c � 2014
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5 ` f 1LTH DEPARTMENT
DEP has provided this form 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, 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. Facility Information
1
System Location: Left / Right front of house, Left / Right rear of house, Left / ' Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Aierec��
2. System Owner
Name
Address (d different from location)
cRy rows
B. Pumping Record
1. Date of Pumping
3. Type of system--
0
ystem:
❑ Other (describe):
A
up cone
State Zip e
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition of Systems
J
6. System Pumped By:
Neil. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
contents were disposed:
t5form4.doc, 06103 System Pumping Record • Page 1 of 1