HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 BRIDGES LANE 12/5/2022 Commonwealth of Massachusetts iECEtvED
ROM City/Town of
System Pumping Record DEC 052022
Form 4 roZn;1%11 Or='sdOt j-H ANDOVEF
►f,_`,LT}I 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 bacl sid rear left right
A. Facility Information BUILDING: front back side rear left rig t
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 21�jd4�
key to move your Address
cursor-do not
use the return it /Town State
key. y Zip Code
2. System Owner:
gab
c-44 b �6C
Name
arum '
Address(if different from location)
City/Town . State Zip C de
2.
_ Telephone Number
B. Pumping Record
1. Date of Pumping to 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe :
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
G D
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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