HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 NORTH CROSS ROAD 8/18/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of AUG 18 2022
System Pumping Record TH
OF NOR
Form 4 TOWN HE LTH 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 C M R 15.351. -- -
HOUSE: front back si rear of right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S tem Location:
on the computer, C�►��J
use only the tab
gp
key to move your ddress 'e
cursor-do not
use the return key. City/Town State Zip Code
2. System Owner:
lab
Name [vim
romin
Address(if different from location)
City/Town State Zip Code
46/a
Telephone Number
B. Pumping Record
1. Date of Pumping Date �2. Quantity Pumped: allons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- - - -
4. Effluent Tee Filter present? ❑ Yes XNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contents were disposed:
S
Cj
22—
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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