HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 MILL ROAD 10/12/2021 Commonwealth of MassachusettsEcE1VED
City/Town of
VER
TMENT
System Pumping Record losOfNOF�fiWA"�
Form 4 NgglA6E*R
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,(O�Rig rea o , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address / ,.
Cityfrown ` State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: h vl,
6. System Pu fnped By:
�� 6 _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiot content&were disposed:
1 S. 41-owelLWas1p,Water
Sign a 4 Haulw YT Date
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