HomeMy WebLinkAboutMiscellaneous - Exception (25)Commonwealth of Massachusetts
W City/Town of
a System Pumping Record NOV - 2 2010
Form 4 TOWN Aa NORTH ANMVV P
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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 �eftfiont�ouse,
se right front of house, left side of house, right side of house, Left
rear of house, righ left side of building, right rear of building, under deck.
Cityrrown
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Zip Code
Stn C� ��l 7Ip Co e
Telephone Number
Date 2. Quantity Pumped:
Cesspool(s) Septic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes 9-60 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson
F5821
Name VehicWUc*nse Number
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
L. . D. , LoWe7l Wast~&
1=
Date
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