HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 221 CAMPBELL ROAD 10/18/2022 -C"\ Commonwealth of Massachusetts RECEIVED
u r City/Town of OCT 18 2022
System Pumping Record VER
Form 4
TOWi\9 Ur NORTH t�NDO
tfiEA;TH pCPARTIIENT
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: < ron back side rear Cft:�Jght
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, rW yt n l�
use only the tab a(
key to move your Addr ss
cursor-do not /��/y/� Z/
use the return City/Town -- L/ '- IL G
yown
key. State Zip Code
2. Syst Owner:
Name
atwn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 4I I
lons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? ❑ Yes
"_A No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component ppumped-
6. System Pumped By:
Dave Tiney _ ___ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
T Lo o here contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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