HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CROSSBOW LANE 8/18/2022 Commonwealth of Massachusetts RECEIVED
City/Town of AUG 18 2022
a System Pumping Record
Form 4 TOHE LLTHDEPARTM DEN OF NORTH PARTMENT
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 si rear eft tg t
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Sys 6&6
on the computer, c% 11A-)Z�j J
use only the tab ---___
key to move your Addre s
cursor-do not
use the return
key. Oftyf7own State Zip Code
2. Sys m Owner:
ab
mme
re�wn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic 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. cation win e contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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