HomeMy WebLinkAboutMiscellaneous - Exception (26)Commonwealth of Massachusetts
City/Town of RECRIV
System Pumping Record
Form 4 MAY - 8 2012
DEP has provided this form for e by local Boards of Health. Other �i�f ►`��$ !� y
information must be substantial) the same as that provided here. Be with our
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 . Le igh ont of ho e, Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Ig ont of building, Left / Right rear of building, Under deck
AddressC �
CD� Cl—L/11)-9—r
'n r
City/Town
State
Zip Codes
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
Statim (� Zip Code—
Telephone Number
Date 2- Quan 'ty Pumped:
Cesspool(s) Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
5. ConditiToF���
fte t w-,�,k � VL 4z:t,�
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Waste Water
F5821
Vehicle License Number
J'(—IC�-
Date
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