HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 7/6/2022 IC RECEIVED
Commonwealth of Massachusetts
City/Town of
a
System Pumping Record 3uL 062022
Form 4
TO ER
HEALTH DEPARTM T
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: ront back side rear left righ
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, /'5 2 9 -
use only the tab
key to move your Address 41
cursor-do not �/� //►� �/
use the return ���
key. City/Town State Zip Code
2. Syysite Owner:
Name
ie�wn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record 6
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? ❑ Yes1z 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. cati 7ere contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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