Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 209 BRIDGES LANE 11/28/2022 Commonwealth of Massachusetts RECEIVE® City/Town of a ° System Pumping Record Nov 28 2022 Form 4 TOWN OF NORTH PARTMENTER DEP has provided this form for use by local Boards of Health. Other ff0W%q 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: fro back side rear le right A. Facility Information BUILDING: front c side rear leftt�rr ttg DECK: under Important:When filling out forms 1. System Location: on the computer, G use only the tab cx© 1 r I j-e5 c n4,— key to move your Address cursor-do not ► 1 4(1�0u er use the return Cityfrown State Zip Code key. 2. System Owner: tab QCA nC ,b Name - _ --- - - return Address(if different from location) City/Town State Zip Code c Telephone Number G B. Pumping Record 1. Date of Pumping Date Z2 - --'_ 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) ICJ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - ----/- -- -- 4. Effluent Tee Filter present?/b Yes ❑ No 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. Lo ion where contents were disposed: LSD Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1