HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 CHRISTIAN WAY 10/5/2021 Commonwealth of Massachusetts
City/Town of p
System Pumping Record TOV'gV0 N
Form 4 HE401pF'llA/DOVER
E,JT
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
focal 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 gh rear of ho , Left/right side of house, Left
Right side of building, Left/Right front of building, a ght rear of building, Under deck
Address
CWrown state Zip code
Z. System Owner.
Name' 1"
Address(if different from location)
Cityrrown Stan
Telephone Number
B. Pumping Record
1. Date of Pumping Date v2 Quantity Pumped: Gauo s
na
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'140 if yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentswere disposed:
G L S. owell Waste Water
Sign e H le 7, Date
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