HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 332 CAMPBELL ROAD 10/18/2022 Commonwealth of Massachusetts
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W° System Pumping Record
Form 4 WNOFN�S"Sk MEND
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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 back side rear eft right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, � Cam`
use onlythe tab l�Y''
key to move your Address
cursor-do not
use the return 'City/Town 'State Zip Code
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2. System Owner:
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Name
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Address (if different from location)
City/Town State Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic 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. Location where contents were disposed:
GLSD
Signature er Date
Signature of Receiving Facility(or attach facility receipt) Date
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