HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 141 MARIAN DRIVE 11/4/2022 Commonwealth of Massachusetts jA.FCOVED
N City/Town of _
R System Pumping Record N�� 42022
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Form 4 FtTH AND T
k CiVvN OF-IVAN�Epp,�iTME�
DEP has provided this form for use by local Boards of Health. Other forms may be usedbut 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 ide rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer, Mar,A�
use only the tab
key to move your Addres
cursor- not
use the return
urn
key. City/Town State
Zip Code
2. System Qwner:
� r I J
eK J e
Name
rnnn
Address(if different from location)
City/Town
^�te Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping —Lb �!��
Date — 2, Quantity Pumped: /75
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe): _
4. Effluent Tee Filter present? ❑ Y�o If yes, was it cleaned? Ye❑ s ❑ No
5. Observed c r
clition of component pumped:
6. System Pumped By:
Dave Tiney N ame Mass 1AA95E
Vehicle License Number
Bateson Enterprises Inc
Company
7.5signatof
ere contents were disposed:
uler
Date -- — ---
signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1
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