HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 962 TURNPIKE STREET 7/6/2022 Commonwealth of Massachusetts IaCEIVED
u City/Town of
o System Pumping Record �u� 06 �022o�ER
Form 4
i O`Nta OF NOR AND
HEALTH DEPARTMENT
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 sid rear a right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, '/ /� f
use only the tab �(aC2 1A(yt 01 1� ✓vl-
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner: _ 1
Name
rerwn
Address(if different from location)
Cityrrown State Zip Code
' lvK5
Telephone Number
B. Pumping Record 1. Date of Pumping Date 30 a 2 Quantity Pumped: canons
;7
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — --- --
4 Effluent Tee Filter present? ❑ Yes EVNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of omponent pumpe
d:
(JlA,9� ifl f'J 2 I
6 System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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