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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FULLER ROAD 12/12/2022 ��GEt�ED Commonwealth of Massachusetts r City/Town of 1ti2022 x System Pumping Record of o�i HAND Form 4 �OHE 1H4oe\' AMEN 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: 5ont back side rear(IF)right A. Facility Information BUILDING: back side rear left right Important:When DECK: under filling out forms 1. System Location: on the computer, r i A Ier use only the tab 9j$' key to move your Address cursor- not �I ��Qyer G use the return '"urn Q 141�_ key. City/Town State Zip Code 2. System Owner: nb LC C -_- � Name ieiwn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 1 Date2. Quantity Pumped: �U/ Gallons 3. Component: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank/ g ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ 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. Location where contents were disposed: rGYL Signatuk o uler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc 11/12 System Pumping Record•Page 1 of 1