HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 720 FOSTER STREET 7/6/2022 Commonwealth of Massachusetts RECEIVED
= City/Town of 6 2022
System Pumping Record
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Form 4 TOWN Or NpEPARTMENT
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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 e ar left
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S stem Lo;��
on the computer, ram/
use only the tab
key to move your AdcTress
cursor-do not G
use the return key. City/Town State Zip Code
2. S ste Owner:
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Name
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Address(if different from location)
City/Town State Lip Code
Telephone umber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye 94 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 n ere contents were disposed:
GLSD
Signature of Hauler OF Date
Signature of Receiving Facility(or attach facility receipt) Date
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