HomeMy WebLinkAboutHolding Tank - Septic Pumping Slip - 1429 OSGOOD STREET 1/6/2023 Commonwealth of Massachusetts RECEIVED
City/Town of JAN p 6 20D
System Pumping Record VM OF
fv),rjTH ANUOVER
Form 4 TOHEAUTH DEPARTPP'ENT
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: fr t back side rear left right
A. Facility Information BUILDING: (fron back side rear le right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, I
use only the tab I � ?--1 osq ca L-+
key to move your Address
cursor-do not ) Cl zC1 ! A n 19-4
use the return City/Town State
key. Zip Code
2. System Owner:
0 tRC C1rou�
t Name
iewm '
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z2 2. Quantity Pumped: Gallons
3. Component: ❑ Tank
Tight Cesspool(s) ❑ Septic Tank ❑[ g ❑ Grease Trap
Other (describe): Vo
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
i
5. Observed condition of component pumped:
No f.�,t4
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
GLSD
Signatur of Hauler Date T,
Signature of Receiving Facility(or attach facility receipt) Date
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