HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 57 CANDLESTICK ROAD 9/19/2022 Commonwealth of Massachusetts BECE►VED
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System Pumping Record SEp 1 92022
Form 4
M To\N OF DEPARTM� Eh T
'AFDEP 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 pumpin date in
accordance with 310 CMR 15.351.
HOUSE: front ba sid reargleftright
A. Facility Information BUILDING: front bac Ide rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, 57 / 11"Alz
use only the tab `
key to move your mess ,} `�
cursor-do not //l gG<�-y �2�} (1
use the return —City/Town State Zip Code
key.
2. System Owner:
CKc
Name
iQrwn
Address(if different from location)
City/Town State 6/7- W.2- ZPl
Code
Telephone Number (/�`
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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: �a
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 auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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