HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 7/20/2022 Commonwealth of Massachusetts RECEIVED
w City/Town of
a System Pumping Record 3uL 2 02022
Form 4
TOHEALTH 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 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: rout b ck side rea eft ight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ,n-_
use only the tab (��7(,
key to move your dress
cursor-do not
use the return key. City/Town State Zip Code
2. Sys tam Owner. ) ///�
dab 1--" �C,C �f V
Name
/elwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
� � U
1. Date of Pumping Date 2. Quantity Pumped:
Gallo"ns
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - -- —
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleanedr�Zyes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 L tion ere contents were disposed:
G �D
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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