HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 NORTH CROSS ROAD 8/18/2022 Commonwealth of Massachusetts RECEIVED
= City/Town of
System Pumping Record AUG 182022
Form 4
M 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 d9 side rear e right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
1 m ion:
filling out forms System Location:
on the computer,
use only the tab GNUS C> 9C/
key to move your Address
cursor-do not /
use the return City/Town State Zip Code
key.
2. System Owner:
rab
Name
/Blinn
Address(if different from location)
City/Town State �O Zip Code'
Telephone Number
B. Pumping Record 0
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 condign of component pumped:
4)cl,
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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