HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 LOST POND LANE 5/31/2022 Commonwealth of MassachusettsECE�v�v
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System Pumping Record Ma`l 31 oovEa
Form 4 WN of NO P M
END
-�O DEP has provided this form for use by local Boards of Health. Other W Vs�SN may be used, but the
information must be substantially the same as that provided here. Before using this form, check with you
local Board of Health to determine the form they use. The System Pumping Record must be submitted b
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 C M R 15.351.
A. Facility Information HOUSE: front bacl side ear eft'
Important:When BUILDING: front back side rear left
filling out forms 1. Satem Loca IOn: DECK: under
on the computer, � � 7i, Duse only the tab ,t�
ke to move your Addr ss
cursor-do not 7,76 K-I�- 2eLz,
use the return City/Town — State Zip Code -
key.
2. Syslam Owner:
Name
imm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 2
1. Date of Pumping Date 2. Quantity Pumped: Ga ons
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:
1
6. System Pumped By:
Dave Tiney _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc where contents were disposed:
LSD
Signature of Hauler Date