Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 27 OAKES 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 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 Inform' ation 1. System Location: Left/Right front of house, Left/ i ht rear of hou , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left g ear of building, Under deck Address ri Citylrown State Zip Code 2. System Owner. Name' Address(if different from location) CityNrown State��� Telephone Number B. Pumping Record tO 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 lam'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System_ Pumped By: .Q� F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Locati nrhere contents^were disposed: G 06well t Wate 5ignVbjre Hauler(' Date t5form4.dm-06/03 System Pumping Record•Page 1 of 1