HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 51 HAY MEADOW ROAD 11/4/2022 Commonwealth of Massachusetts
w City/Town of
Gov 0 4 2022
System Pumping Record NOR kT%ANM�N-�a
Form 4 jo A%ASPIL�HpEpPR
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 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 ac side rear left ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, — I ����)
use only the tab /
key to move your Address
cursor- not
use the return
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urn It (k/211-
key. City/Town
State Zip Code
2. Syst Owner'
rob
Name " SOS
retain
Address(if different from location)
Cityrrown State
Zip Code
-- __ Telephone Number
B. Pumping Record
1. Date of Pumping
Dat 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Se tic Tank
�� p El 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 N ame Mass 1AA95E
Bateson Enterprises Inc Vehicle License Number
Company
7. Location where contents were disposed:
LS
Signatu of Hauler `
Date --
Signature of Receiving Facility(or attach facility receipt) Date
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