HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 546 SHARPNERS POND ROAD 12/12/2022 RECEIVED
Commonwealth of Massachusetts
City/Town of 0Ec 122022
System Pumping Record TOWN OF NOS -fMT
O
Form 4 HEALTH DEPARTMEN
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 bac 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, C.fW! l�,v, (� t
use only the tab / S�e `cS Qon
key to move your Address
curuse the
returndo U L"
use the return CCiityr ownState1 � O
key. y Zip Code
2. System Owner:
Name
iwmn
Address(if different from location)
CityfTown State Zip Code
61,0 -6giy
Telephone Number
B. Pumping Record
1. Date of Pumping Date 7 2. Quantity Pumped:
�r Gallons
3. Component: ❑ Cesspool(s) Ill Septic Tank ❑ Tight Tank/— g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes J� No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
PNam,
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ation where contents were disposed:
GLSD
12 2 -- —
I� �
Signature o a r Date
Signature of Receiving Facility(or attach facility receipt) Date -
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