HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 381 SUMMER STREET 1/6/2023 RECEIVED
CoinvT=wealth of Massachusetts
=- City/Town of J AN � 61W
System Pumping Record �UBfHASJDOVER
HE�TH DEpARTMENT
_--s form for use by local Boards of Health. Other forms may be used, but the
substantially the same as that provided here. Before using this form, check with your
-;n to determine the form they use. The System Pumping Record must be submitted to
eatth or other approving authority within 14 days from the pumping date in
.'OCMR 15.351.
HOUSE: fron back side rear eft right
A. Facility Information BUILDING: front back side rear left right
Impor�- a;�r- DECK: under
filling: -ti `. Sys Location:
on the
key tc _rA.-CFess
\ AA
curse : N /�(1�c7J2�_- __ _ _L — o'ik14f
use t—_ _ _ - � - State Zip Code
key.
2_ Sy-stem Owner:
1
4MP Cc-��cu
Address(if different from location)
Cityffown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 }b 2. Quantity Pumped: /o OG
Date 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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. VS_ig_natuo6H
ntents were disposed:
Date
- . — - -
Signature of Receiving Facility(or attach facility receipt)— Date
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