HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 ROCKY BROOK ROAD 5/31/2022 Commonwealth of Massachusetts '+ECEjvEu
w City/Town of MAy 312022
a System Pumping Record ANoovER
Form 4 ToNIN of NDEpAME OVITNT
HEp,1.TH
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 rea left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, 2
use only the tab I 3 L - G v(1
key to move your Address
cursor-do not
use the return itY/Town" State - Zip Code
key.
VQ 2. SystW Owner:
-SMW
Na le
ierun
Address(if different from location)
City/Town State/' / —Y6 Code
Telephone Number (jJ�
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallons��
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. Loc here contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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