HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 BROOKVIEW DRIVE 5/31/2022 Commonwealth of Massachusetts
City/Town of MAC 3 2022
a System Pumping Record T ,\NoOVEv�
Form 4 TOWE OT DEPARTMeW
'wM Sy H
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: front back side rea Ie right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, �15 ��� fM`
use only the tab k7�XXJ
key to move your Address
cursor-do not y✓Vr<
use the return ity/Town � State Zip Code
key.
2. System Owner:
,ab 1yU 6'�I U
Name
ierwn
Address(if different from location)
CitylTown Staten l� ^�� odg
Telephone Numbe`rrf
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
ate Gallon
3. Component: ❑ Cesspool(s)Yseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye fy 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:
LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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