HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 GILMAN LANE 5/31/2022 Commonwealth of Massachusetts �r,-GeWeo
u City/Town of y 312p22
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System Pumping Record MA TNW00\1 R
Form 4 jOWN O�/� Hp-PPAR�MENj
DEP has provided this form for use by local Boards of Health. Other formes 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: front back Oear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Loca ion:
on the computer, / / /L,�
use only the tab I '.` �—
key to move your ress' , / Ole
cursor-do not /1A �/[(�1�,/,�, K l�
use the return
key. C ty/Town � State Zip Code
2. Sys em Owner:
r X
rerwn Nifne
Address(if different from location)
City/Town State ip Code�
Telephone Number
B. Pumping Record
1
1. Date of Pumping Da e 2. Quantity Pumped: allons
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 here contents were disposed:
LSD
Signature of Hauler Da
Signature of Receiving Facility(or attach facility receipt) Date
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