HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 55 STONECLEAVE ROAD 11/28/2022 RECEIVED
�LN Commonwealth of Massachusetts
= City/Town of Nov 2 8 2022
System Pumping Record T(?V�NU�NUR-iHANDOVEIi
Form 4 H_NLTH DEPARTMENT
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: fron back side rear left
A. Facility Information BUILDING: ron back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ��
use only the tab L
key to move your Address,
cursor-do not ./A"%
use the return Citylrown State Zip Code
key.
r�
2. System Owner:
/3rt'e a,
Name
rerun
Address(if different from location)
C
Citylfown State Co �
Telephone Number 0,7 S
B. Pumping Record
ADO�
1. Date of Pumping pate -- — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) ff'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --
4. Effluent Tee Filter present? ❑ Yesf�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
l�/wnot
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bat_eson Enterprises Inc
Co mpany
7. Location where contents were disposed:
GLS
Signature auler Date
Signat re of Receiving Facility(or attach facility receipt) Date
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