HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 495 REA STREET 11/4/2022 Commonwealth of Massachusetts
City/Town of
System Pumping Record Npv �ti021
Form 4 tlaRvN Al ANT R
TpWN`�NOEpN51
DEP has provided this form for use by local Boards of Health. Other forms y 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 CM 15.351. — --
HOUSE: fron back Ide rea left right
A. Facility Information BUILDING: front ac side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not n jai c
use the return City/Town State Zip Code—
key.
2. System Owner: :
Fc-e C<zw
Narrfe
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Z 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed Condit' of component pumped:
s^Ma
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L n where contents were disposed:
GLSD
II 2
Signature Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
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