HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 BRIDGES LANE 2/22/2023 Commonwealth of Massachusetts RECENED
City/Town of _
a System Purnping Record FEB 2 22023
Form 4
TOHOF NoRTH ER
HEALTH DEPARTMENT
NT
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 Syste.m 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 ba ' e a left right
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 tab (/
key to move your d r ss
cursor-do not
use the return
key. CI yawn State Zip Code
2. System Owner:
ub
Name
nrwn r
Address(if different from location)
City/Town . State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity P
D y Pumped:
e
Ga s
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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature Hauler
Da
Signature of Receiving Facility(or attach facility receipt) Date
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