HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 BANNAN DRIVE 4/3/2023 IL Commonwealth of Massachusetts RECEtvED
City/-1-own of
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System Pumping Record
Form 4 TOWN OF
ER
DEPARTMENT
HEA
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
I the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. -
HOUSE: (-fronb back side re left right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
jon the computer,
I use only the tab 62— 'Raw10'/-1 Oc—
key to move your Address
cursor-do not N.h( I V L`+ O I 116, ,15
use the return City/Town State Zip Code
key.
j 2. System Owner:
Xy ?fcc) s
Name
rcrmn '
Address(if different from location)
City/Town State Zip Code
'Q I�4 -Sej6-C�C�cd
Telephone Number
B. Pumping Record
1. Date of Pumping Date — 2, Quantity Pumped:
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
i
5. Observed condition of component pumped:
00( M�
1
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
i Company
7. on where contents were disposed.
LSD
Signature ON—a— r Date
Signature of Receiving Facility(or attach facility receipt) Date
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