HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 RALEIGH TAVERN LANE 12/22/2022 �ECE1V�p
� Commonwealth of Massachusetts
F City/Town of pEC 2ti ANpovEa
System Pumping Record ov1405f' N1Etv
Form 4 �pNN �NpEPA�
Y' A
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 a right
A. Facility Information BUILDwG: nt back side rear left right
Important:When DECK: under
filling out forms 1. System Loc tlon:
on the computer,
use only the tab
key to move your Tss
cursor-do not
use the return
key' City/Town State Zip Code
2. System Owner:
Q
Name
Address(If different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of P jrnping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): /
4. Effluent Tee Filter present?/ Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
be MGM
6. System Pumped By
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. tion where contents were disposed:
G L S'�,
Sign ure of auler Date 2L
Signature of Receiving Facility(or attach facility receipt) Date
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