HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 RALEIGH TAVERN LANE 8/18/2022 Com«ionwealth of Massachusetts REcEtvEo
City/Town of AUG 1g20 l
System Pumping Record ovEa
Form 4 TOWN OF NORTHR MENT
HEATH DEPA
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 bac side rea<leDright
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Syst�m,Loc Ion:
on the computer,
use only the tab
key to move your ress �jJn� P�
cursor-do not G� '`"'`� ID 2f
use the return Cil /Town
key. y State Zip Code
2. Sys e� r:
,e
4
Name ,r
iewn
Address(if different from location)
City/Town StateD Code
Telephone Number
B. Pumping Record
I?
1. Date of Pumping 2. Quantityns
Date Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): ---
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L to here contents were disposed:
GLSD
Vz
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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