HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 WILLOW RIDGE ROAD 10/7/2022 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
OCT 0 7 2022
Form 4
TOYVN OF NORTH ANDO EF
DEP has provided this form for use by local Boards of Health. Other KRFpft0 ut 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.
A. Facility Information
Le i Righ ron of house, Left/Right rear.of house, Left/Right side of house, Under Decl
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
iemm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dat�^°23 2. Quantity Pumped: Gallons
3. Component". ❑ Cesspool(s) Septic Tank ❑ Tight Tank ElGrease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of co ponent pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. LocalLon where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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