HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 168 CAMPBELL ROAD 12/5/2022 �\ Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record DEC 052022
Form 4
I'OWN'N ER
TO 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: on back side rear left right
A. Facility Information BUILDING:(;C—rout back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, � / 8 �� p ``
use only the lab tQ V•.- y
key to move your Address
cursor-do not ► r
key the return City/Town f
State Zip Code
Y
„n 2. Sysrter Owner: °
Name
ntmn
Address(if different from location)
City/Town State /L Lt Xr
�y
l/ V
Telephone Number
B. Pumping Record
II � j o0
1. Date of Pumping oat 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Ti ht Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes7 No If yes, was it cleaned? ❑ Yes No
5. Observed condition of component pumped:
A i
T
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
LSD
Signature ofjHau a e
fl
Signature of Receiving Facility(or attach facility receipt) Date
i
I
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