HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 SPRING HILL ROAD 8/29/2022 (C\ Comnionwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 AUG 2 9 2022
DEP has provided this form for use by local Boards of Health. Other%YMQ I1TRAW0 t Fkhe
information must be substantially the same as that provided here. Be1Hic �IEtRNdheck 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 ho side rear left
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, / p
use only the tab �� S A,
key to move your Address -"
cursor-do not
use the return Cit own
key. y State Zip Code
2. System Owner:
nb
SIG&L �crtl�ay
Name
gtwn
Address(if different from location)
City/Town State _ Zip Code
i j77 - ?_s � --Sb `E1�
Telephon Number—
B. Pumping Record f
1. Date of Pumping !� ��. Quantity Pumped:
Dat Gallons
3. Component: ❑ Cesspool(s) �epticTank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): f - ---- --
4. Effluent Tee Filter present? E Yes ❑ No If yes, was it cleaned? �es [] 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:
1
GLSD
I
Signatur auler D
i
1
Signature of Receiving Facility(or attach facility receipt) Date
i
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