HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 FULLER ROAD 4/19/2022 Commonwealth of Massachusetts
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System Pumping Record APR pov�R
N
Form 4 �pWN OF NpEPAR MENT
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Left/Right front of house, Lfftj Right r of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. System Locati n: Left/Right side of building Le /Rig t front building, Left/Right rear of building,
on the computer, /,I 1
use only the tab (/YG
key to move your d ess
cursor-do not /� _ MA
use the return ityrrown State Zip Code
key.
2. Sy
m Owner;
FN me
ream
Address(if different from location)
MA
Cityrrown St zt/
Zi Code
?_ 3 a
Telephone Number
B. Pumping Record
1. Date of Pumping Date *Septic
2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes-kNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tin_ey Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ca � n where contents were disposed:
GLS
Signature of Hauler Date �C�J
Signature of Receiving Facility(or attach facility receipt) Date
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