HomeMy WebLinkAboutMiscellaneous - 50 TURTLE LANE 4/30/2018 (3)-4
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
Health. Other fora
DEP has provided this form for use by local Boards 1
information must be, substantially the same as that f7
local Board of Health tQ determine the form they us
the local Board of Health oro-oM r approving authority.
be used, but the
this form, check with your
;ord must be submitted to
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of ho Right fent of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of ding
Udy-rrown
2. System Owner.
Name
Address (rt different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
t'j����-9
State
Zip Code
Stat Zip CDde
Telephone Number (�
10 —� 2- - Io
Date 2- Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes allo
5. Conditio of System-
7.
ystem
If yes, was it cleaned? ❑ Yes ❑ No
�� D 911�ls � C --L
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.
contents were disposed:
Lo r d- 10
Date
t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1