HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 GRANVILLE LANE 5/20/2022 �L\ Commonwealth of Massachusetts RECEIVED
City/Town of p NZZ
So System Pumping Record MAY 2
JER
Form 4 TO\NN OF NORTH ANDO TMENTT
HEALTH DEPAR
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: <jg6Dack side re r left ri ht
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Lo ation:
on the computer, ,/J 'n/ /l G 14 fL �
use only the tab
key to move your Addr 9
cursor-do not `'V
use the return City/Town State Zip Code
key.
2. System Owner:
dab
-7 -e
Name
ielwn
Address(if different from location)
City/Town State �- Zip Coda
a3 - VGA
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: GallonsB
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -
4. Effluent Tee Filter present? Yes ❑ No 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 on ere contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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