HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 VEST WAY 9/19/2022 Ftr�ENt.� �
Commonwealth of Massachusetts
City/Town of SEP 192022
' pVER
a System Pumping Record EOFtoEPATMSNT
TO HN
Form 4
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
within 14 da sumping Record must from a pumping date inubmitted to
the local Board of Health or other approving Y
accordance with 310 CMR 15.351. HOUSE: �frback side �rearft Ig t
II' it Information BUILDING: front back side rear left right
A. Facility DECK: under
Important:When ovation:
filling out forms 1. System L
on the computer. /� /)
use only the tab
key to move your Ad rAs ,,.. ��////11�^ / )/
Albx l/
cursor-do not ATT State Zip Code
use the return City/Town
key.
2. System Owner:
Name
reran
Address(if different from location)
Stat Zip Code
City/Town /�`,
Tele/phoone Number
B. Pumping Record l
97�
1. Date of Pumping Date
2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Aleptic 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 pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Vehicle License Number
Name
Bateson Enterprises Inc
Company
7. L to here content ere disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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