HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 427 WINTER STREET 2/22/2023 RECEIVED
mow. Cornmonwealth of Massachusetts
- C4tpTown of FEB 2 2 2023
_ System Pumping Record
x rOWN OF
HEALTH DEPARTM NT R
0r=P hsas V :s form for use by local Boards of Health. Other forms may be used, but the
d1 tst be substantially the same as that provided here. Before using this form, check with your
mm(Fifh to determine the form they use. The System Pumping Record must be submitted to
of Health or other approving authority within 14 days from the pumping date in
+ . + wth 310CMR 15.351. - -
HOUSE: froq� back Ide rear le righ
A. Facility information BUILDING: front�ack side rear left right
Important "d e„ DECK: under
filling"kr= 1- Sysaetrn t c-arion:
on the f/ 2le3-
use on)y t1V'tat 7 Z r W►n
key to nvve,yorar AicFess —
curs<x-cc rct
use t.'�e retum
key. Cry-Town State Zip Code
2- System Owner:
Sc(C,i. l lA k i
Marne
A4tlress(if different from location)
C3ty/fown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1�3y z3 - — 2. Quantity Pumped: /OOU
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- --- — -- --
4. Effluent Tee Filter present? ❑ Yes .1 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�OCIb.�
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company —
7. Lkre
re contents were disposed:
Sler Date
Signature of Receiving Facility(or attach facility receipt) Date
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