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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 SUGARCANE LANE 11/4/2022 Commonwealth of Massachusetts City/Town of _ R� R System Pumping Record v p �2oti1 a Form 4 OVER N OF NO pPA MEND DEP has provided this form for use by local Boards of Health. OtherSigwWaW 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: ffbn back side rear left ht A. Facility Information BUILDING: r��t back side rear left right Important:When DECK: under filling out forms 1. System Location: on the computer, / 1� use only the tab f A SQ Q1('C0-V\Q key to move your Add re cursor-do not use the return Aj. (ICJ-�Ol nr key. City/Town St�at�e/ Zip Code 2. Sy Zx�- e-1- Owner: �O© Name niwn Address(if different from location) City/Town - - - - - _--- -- State Zip Code —�P I -?- `7017 Telephone Number B. Pumping Record 1. Date of Pumping l I /( �O U Date - -- 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank 9 ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed co dition of component pumped: 6. System Pumped By: Dave Tine y Mass 1AA95E Name Vehicle License Number -- Bateson Enterprises Inc Company 7. Lo 'on where contents were disposed: G Signature of auler Date - Signature of Receiving Facility(or attach facility receipt) t5form4.doc• 11/12 System Pumping Record •Page 1 of 1