HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 142 DUNCAN DRIVE 4/3/2023 Commonwealth of Massachusetts RECEIVED
w City/Town of r
System Pumping Record
Fo rni 4 TOWN ZTH[)EPARTMENTER
HE
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 System 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 CM 15.351.
HOUSE: front bac side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, +
use only the tab 1 n Cam r
key to move your Address
cursor-do not F_ �n kT I Ac,
use the return key. CitylTown State Zip Code_
2. System Owner:
ub
An �)lcen a
Name
irrwn '
Address(if different from location)
City/Town . State _ Zip Code
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
5. Observed condition of component pumped:
(V6 n
6. System Pumped By: I
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
GLSD
Signature of Hauler Date h L3
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc 1 t/12 System Pumping Record•Page 1 of 1
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