HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 VEST WAY 10/31/2022 t ' RECENED
:�L\ Commonwealth of Massachusetts OCT 312022
City/Town of
f; TOLE�TH pEPARTMENTER
System Pumping Record
Form 4
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tt
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left/Right front of hous QL?ftLeft
Right rear of house, Left/right side ofhouse, Left
Right side of building, Left/Right front of b /Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not N MA
use the return City/Town State Zip Code `1
key.
,a
2. System Owner:
Name
rzrun '
Address(if different from location) —
MA
City/Town State Zip Code
� - T�Z4
Telephone Number
B. Pumping Record
1. Date of Pumping Z �11-72. Quanti Pum ed:p g Datep 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 o component pumped:
f
Nd�
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD o I Waste Water
Signat r Date
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