HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 11/4/2022 Commonwealth of Massachusetts
w City/Town of
System Pumping Record �zo
Forrn 4
Ow P N 0�NNO� P� MAN
DEP has provided this form for use by local Boards of Health. Other fo�mg-1(>:{�q 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 C M R 15.351. -- - - -
HOUSE: front bac s�err left rightA. Facility Information BUILDING: front backr left
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, Aw A('
use only the tab (J�
key to move your Add ss
cursor-do not
use the return Cit /Town Y` ` — - —
key. y State Zip Code
2. Sy�m Owner:
1
Name -- - - —
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate^ 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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc_
Company
7. Location where contents were disposed:
GLSD
Sign of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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