HomeMy WebLinkAbout- Septic Pumping Slip - 141 NORTH RAMP ROAD 8/18/2022 -C\ Commonwealth of Massachusetts REGE►veo
T
CiofZSystem Pumping Record Form4 TOWN OFNOEPA TMEN'T
HEpj,TH p
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 side rear left right
A. Facility Information! QQ BUILDING: front ac side rear left r�
Important:When �� 6 �J DECK: under
filling out forms 1. System Location:
on the computer, a \�,�. A
use only the tab �l;`d �J I(uxe-vtC� A �(--V
key to move your Address
cursor-do not A) ►,q� M
use the return Cit /Town M'7
key. y State Zip Code
ub 2. System Owner:
'i kk MCC (CK34
Name
erom
Address(if different from location)
City/Town State Zip Code
!27 9 -- g0`7— O�s x-,C
Telephone Number
B. Pumping Record
1. Date of Pumping 2. QuantityPumped: Gallons
Date p 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. Location where contents were disposed:
LSD
6141
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record Page 1 of 1
