HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 22 RALEIGH TAVERN LANE 11/4/2022 Commonwealth of Massachusetts RECE��ED
City/Town of _
System Pumping Record �10 0 42022
Form 4
1ONIN O� 0EPAR tMEW'T
DEP has provided this form for use by local Boards of Health. OtLv
heAforms 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: ,fro back side rear\ right
A. Facility Information BUILDING: —front bask side rear right
Important:When DECK: under
filling out forms 1. System L cation:
on the computer,
use only the tab �PAJ
key to move your ddre �Jn�
cursor-donot
use the return
urn
key. City/Town State
Zip Code
2. System Owner:
raD
��J✓'2�/y Cl Cf �c��
Na
re�wn
Address(if different from location)
City own State
Zip Code
— Te I one Number �
B. Pumping Record �-
1. Date of Pumping 2. Quantity Pumped: 7:
Date y ped: 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. Obs rued condition of component pumped:
6. System Pumped By:
Dave Tiney N ame Mass 1AA95E
Vehicle License Number
Bateson Enterprises Inc
Company
7. VL ' n where contents were disposed:
i
9ture
uler
eceiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Pace 1 of 1
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