HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 NORTH CROSS ROAD 8/18/2022 Commonwealth of Massachusetts ECe\-�e°
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System Pumping Record
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Form 4 �N0�0& �.�o
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DEP has provided this form for use by local Boards of Health. Other ms 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 sl e r r I�e right
A. Facility Information BUILDING: front back side rear left right
DECK: under
j Important:When
filling out forms 1. System Location:
on the computer,
use only the tab _ �� Gft�
�� Q
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
tab
4
Name
tetwn
Address(if different from location)
City/Town State Zip Code
;�T'� t
Telephone Number
B. Pumping Record
1. Date of Pumping ZSeptic
Quantity Pumped:Date Gailons
3. Component: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - -
4. Effluent Tee Filter present? ❑ Yes 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. Location where contents were disposed:
GLS
.7 S
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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