HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 DUNCAN DRIVE 7/6/2022 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 6 2022
System Pumping Record
Form 4 TGViN HEALTH'ORTH DEPARTMENTER
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(
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 back sid rea ' left
Important:When BUILDING: front back side rear left
filling out forms 1. System Location:
on the computer, /// � DECK: under
use only the tab -
key to move your Ad es
cursor-do not y v r ' �
use the return 'City/Town State Zip Code ^�
key.
2. System Owner:
�.P< �v
Name
rertm
Address(if different from location)
City/Town State � n� � ! ip_Code
Telephone Number
B. Pumping Record
1. Date of Pumping �1027 -dl 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? ❑ Ye 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 w"disposed.
LS
Signature of er Date