HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 657 FOREST STREET 2/22/2023 aECE`VED
Comte. wealth of Massachusetts
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System Pumping Record &tAo OvER
Flom 4 TO\�OF tA0 RSMEtA
. z ��s Form for use by local Boards of Health. Other forms may be used, but the
s - +a - .. substantially the same as that provided here. Before using this form, check with your
cm S� to determine the form they use. The System Pumping Record must be submitted to
t,ne. t a-v c`Health or other approving authority within 14 days from the pumping date in
- - ry 3'0 CMR 15.351. —. -
HOUSE: front back side rear le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
on
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key t-- :%,r AWims
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i
ke -- - State Zip Code
S-1 sem Owner: 1
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Address(if different from location)
Gty/Town State Zip Code
56S- - Z 3 (� 2
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z 3 2. Quantity Pumped: Gallons
I 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 condit' n of component pumped:
6. System Pumped By:
Dave Tiney _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ion where contents were disposed:
GLSD
- _ 2-
Signature o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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