HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 317 RALEIGH TAVERN LANE 12/12/2022 RECE►VEU
Commonwealth of Massachusetts p�� 1`i2022
City/Town of pNDOVEA
System Pumping Record TOHEAjHt) TMENT
Form 4
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: fron back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, ^
use only the tab 9-41e t cl ye rn
key to move your Address
cursor-do not K3. f
use the return Cit /Town
key. y State Zip Code
2. System Owner:
dab
\M CCAr>1p►c»
Name
inwn
Address(if different from location)
City/Town State Zip Code
Co 13- 1�5SZ- ?'yCf
Telephone Number
B. Pumping Record
1. Date of Pumping Date } 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight g ❑ 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:
porn"
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 1,aation where contents were disposed:
GLSD II
—
Signatur uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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