HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 DUNCAN DRIVE 1/6/2023 Commonwealth of Massachusetts RECEIVED,
City/Town of JAN 6 Z0D
a System Pumping Record
Form 4 TC HEA JH�DEPAR MENTER
HEAD
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 back side rear left(,ri ht
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 C a,n SJ
key to move your Address
cursor-do not n�yv� ✓1,.� �
use the return
Y• 1 ' �S
key. City/Town State Zip Code
2. System Owner:
taD
1h0k\T l q S C fl
+ Name ("►'
� v
reimn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pum in f
P 9 Date ZZ 2. Quantity Pumped: -
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes O No If yes, was it cleaned? ❑ Yes El No
5. Observed condit'on of component pumped:
C(YVz
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L lion where contents were disposed:
LS
Signatu f ler Date
Signature of Receiving Facility(or attach facility receipt) Date
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