HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 ROCKY BROOK ROAD 12/5/2022 Commonwealth of Massachusetts BECENED
City/Town of
System Pumping Record pEC 05Z�Z2
Form 4oFt ovER
TOW�N O NDEPAR MENT
DEP has provided this form for use by local Boards of Health. bVeir 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: front back side Year le righ
A. Facility Information BUILDING: front back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer, k
use only the lab
key to move your ddress
cursor-do not A ' n 10��
use the return City/Town State
Zip Code
2. System Owner:
re
"(\
Name
morn
Address (if different from location)
City/Town State _ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z Z 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) i ] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): 1
4. Effluent Tee Filter present? ❑ Yes 0 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
!�/GC'lr►�c 1
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, n where contents were disposed:
GLS
��IZzIZz
Sign auler Date
Signature of Receiving Facility(or altach facility receipt) Dale
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