HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 86 BROOKVIEW DRIVE 7/6/2022 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record JUL 0 6 2022
.` Form 4
TOWN OFH ER
DEPARTM LAT
DEP has provided this form for use by local Boards of Health. Otherr 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 side rea- 'left
Important:When BUILDING: front back side rear left
filling out forms 1. S st m Location:
DECK:
on the computer, under
use only the tab ws�_ 2
key to move your Address � ?
cursor-do not
use the return key. ity(Town State Zip Code
2. System Owner:
/"K f P9
Name
renm
Address(if different from location)
City/Town State Zip Code�
Telephone Number
B. Pumping Record )
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------- —
4. Effluent Tee Filter present? ❑ YeskNo 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. ion-where contents were disposed:
-- -- --------- ------------
Signature of Hauler Date