HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 HAY MEADOW ROAD 11/4/2022 Commonwealth of Massachusetts ��E�v��
= City/Town of
System Pumping Record N�� 42o2Z
Form 4
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DEP has provided this form for use by local Boards of Health. OtheltYq�l "V%e 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 side rear eft right
A. Facility Information BUILDING: ont back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 9C jg"40(,�'
key to move your AtTdr ss
cursor-do not D
use the return
key. ity/Town State Zip Code
2. Sy tem Owner: '
iaD W W
Name
mom `
Address(if different from location)
City/Town St 11'� A3� e
Telephone Number
B. Pumping Record
1. Date of Pumping QuantityPumped:ate p allons
3. Component: ❑ Cesspool(s) 4s6ptic Tank ❑ 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 Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
G
o:�
Signature of Hauler 77 Date
Signature of Receiving Facility(or attach facility receipt) Date
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