HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 LOST POND LANE 10/7/2022 Commonwealth of MassachusettsEc��`'��
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System Pumping Record OCR � oovER
Form 4 NNN OF NEE FR MEND
M DEP has provided this form for use by local Boards of Health. Other formOsM 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 lefty right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. S stem L cation:
on the computer,
use only the tab
key to move your Address
cursor-do not rung t 9
key.
use the return City/Town 1 —` I" ` State Zip Code
2. System Owner:
tab
Name
rerwn
Address(if different from location)
City/Town State^! l! � Zip ode
Telephone Number [/
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons ��J
3. Component: ❑ Cesspool(s) 4 Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye zo 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; - auler Dates
Signature of Receiving Facility(or attach facility receipt) Date
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