HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 COLONIAL AVENUE 8/18/2022 -C\ Commonwealth of Massachusetts RECOVED
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o a
System Pumping Record AUG 182022
Form 4
TOWN ER
HEALTH DEPARTMENT
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 ack side rea<lD right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. S stem Lo tl0
on the computer,
use only the tab V
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cursor-do not
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use the returnAAX i
City/Town 9tate Zip Code
2. Sy tem Owner:
roe � /
Name
,ewn
Address(if different from location)
City/Town Stat%3' 6n w _,Zip Code
Telephone Number
B. Pumping Record �I
1. Date of Pumping Date 2. Quantity Pumped: Gallons
V
3. Component: ❑ Cesspool(s) 4septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- ---- -
4. Effluent Tee Filter present? ❑ Yes JNo 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. to here contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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