HomeMy WebLinkAboutSeptic Pumping Slip - 19 BEAVER BROOK ROAD 12/22/3201 Commonwealth of Massachusetts
City/Town of
a
System Pumping Record ��
Form 4
DEP has provided this form for use by local Boards of He th. O er forms may be u ed, but the
information must be substantially the same as that provid rm, check with your j
local Board of Health to determine the form they use. The ust be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System--Lac 'on: Left front of house, right front of house, left side of house, right side of houst. eft
rear of house right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: !�
v�
Name
Address(if different from location)
City/Town Stat7q q'-"qCp 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 0-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syrstem:
v
t(2,U-et tom.
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
.L.S. per �Water
—0 /
Signature Ha Date
t5for m4.doc-06/03 System Pumping Record•Page 1 of 1
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