HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 11/2/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health.Other forms may 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 igh re�houseeft/right side of house, LeftRight side of building, Left/Right front of building, a Rilding, Under deck
Address \
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CiWown State- Cod
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2��t�uantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 9-teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? MYIM�❑ No
5. Condition of System: V�J�
6. System Pumped B-�� l �-�
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S. wel aste Water
Sign a Date
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