HomeMy WebLinkAboutMiscellaneous - 91 VEST WAY 4/30/2018Commonwealth of Massachusetts
_ City/Town of
System Pumping Record - - - - -
Form 4
S. By ft��
DEP has provided this form for use by local Boards of Health. Ot er forms€rYQI �;`���d, b the
information must be substantially the same as that provided here Before using this formck with your
local Board of Health to determine the form they use. The Syste Wig' b submitted to
the local Board of Health or other approving authority. HEAL. ri t7
A. Facility Information
1. System Location. ft` rout of house right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
q ( `l1(2� lj"-'� i
Cityrrown State
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Zip Code
State`7 Zip Code
Telephone Number
2. Quantity Pumped:
Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: V\-
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Locatis�a.- ere contents were disposed:
L.S.
Signature
F5821
Vehicle License Number
Date
,a&—
t5form4.doc• 06103 System Pumping Recons • Page 1 of 1