HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 208 OLD CART WAY 12/5/2022 �\ Commonwealth of Massachusetts BECEIVEU
City/Town of _ _ SEC 5 2022.
Record ANDO
System Pumping
F o r r1� 4 t C)VVNNUR N VER
HEALTH 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: front back side rear left righ
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, „p ' ^� �1 ILi Cl
use only the tab ti L(>Q ^t'
key to move your Address
cursor•do not i 'r
use the return key. City/Town Stater' Zip Code
2. System Owner:
,e
Name
Isom f
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) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? e Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
61-Mr.- '
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L 'on where contents were disposed:
LSD
Sign a auler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc• 11/12
System Pumping Record •Page 1 of 1