HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 426 SUMMER STREET 5/20/2022 AFCOVED
�L\ Commonwealth of Massachusetts
City/Town of MAY 2 2022
? u ANpOVER
° System Pumping Record jo NOFNORTH TMENT
Form 4 "EAl-TVA DEPAR
M
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. ------- --
HOUSE: fron back side re le r11 ight
A. Facility Information BUILDING: front ac side rear left right
DECK: under
Important:When
filling out forms 1. Sy t m Location:
on the computer,
use only the tab
key to move your Ad res
cursor-do not / `"/q fy/
use the return City/Town/Town /'�/ ` 9Y State Zip Code
key. y
2. AWZ
er:
rab
Name
ie�urn
Address(if different from location)
City/Town State <Zio Cod �
Telephone Num�ber
B. Pumping Record
1. Date of Pumping a Date o
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - —
4. Effluent Tee Filter present? ❑ Yes0 o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises_Inc
Company
7. Lo here contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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