HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 242 LACY STREET 2/22/2023 Cr wealth of Massachusetts �ECEwEp
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Systems Pumping Record No�T"ANENT
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-7 " this form for use by local Boards of Health. Other forms may be used, but the
r•rrr—are_t —1-sv be substantially the same as that provided here. Before using this form, check with your
ctza :�-math to determine the form they use. The System Pumping Record must be submitted to
-- B_:si at Health or other approving authority within 14 days from the pumping date in
wtt 310 CMR 15.351.
HOUSE: fron back side rear left righ
A. Facility Information BUILDING: front back side rear left right
Importar+a .fir DECK: under
filling out ft=s 1_ S*st n Location:
on the
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key. r o"m State Zip Code
2- System Owner:
Qn
Address(if different from location)
Citylrown — -- State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping - 2. Quantity Pumped:
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:
Iu�rM��
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company — — —
7. tion where contents were disposed:
GLS
0 - - -- - - ___ - - -- - - —
7
7�91err 2)�sl_z�Signature Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1