HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 CRICKET LANE 11/28/2022 Commonwealth of Massachusetts
City/Town of REc��v�o
System Pumping Record O
ti
' 0 Form 4 NOv $ opvER
F J`QRZ PR MEND
DEP has provided this form for use by local Boards of Health. Oth 6 vvi* a used, but the
information must be substantially the same as that provided here.TZO sing 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 sid rear left GEE)
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. ?Sstj Location:on the computer, C /i'r'�+G.�►— '
use only the lab _
key to move your Address
cursor-do not ��` v'—'�""•` ��L/
use the return j
key. City/Town State Zip Code
a
2. System Owner:
Name
rown ' --
Address(if different from location)
City/Town State / / '� 'p Code_
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
-- -
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe): _-
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of componentpumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Loca here contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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