HomeMy WebLinkAboutSeptic Pumping Slip - 770 FOREST STREET 12/18/2015 Commonwealth of Massachusetts
C����
�
City/Town of
7�:�'1��
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, Information
1. System Locatio a r Rig tlront of ho e, Left/Right rear of house, Left/right side of house, Left/
Right side of bull mg, Left/Right front of building, Left/Right rear of building, Under deck
Address
Udy/Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown ' stater 4 1ps 7de ;
Telephone Number
]`r
B. Plumping JRpcord
1. Date of Pumping sate 2. Quantity Pumped: Gallons
;.
3. Type•of system: ❑ Cesspool(s) ❑ ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes El, o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: A
6
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L=GLSQ
e contents were disposed:
Low ell Waste Water
Sign a Haule Date
0orm4.doc•08/03 System Pumping Record•Page 1 of 1