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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 129 CHRISTIAN WAY 4/3/2023 VE'r 'Jev Ctwnummwealth of Massachusetts fTown of peg ©`����3oo'JER System Pumping Record ofNoaP AMEND F;Cdu 4 SO NEp,��NA tiiis form for use by local Boards of Health. Other forms may be used, but the be substantially the same as that provided here. Before using this form, check with your of Headth to determine the form they use. The System Pumping Record must be submitted to fte kcal Board of Health or other approving authority within 14 days from the pumping date in accaftarice with 310 C M R 15.351. - HOUSE: fro t back side rea left: right A. Facility information BUILDING: front back side rear eft right Important Wriaa DECK: under filling oarf ions 1- Stem Location: on the cor_:saz., use orJy the tw17 -S ( key to nwwe yw AdAess cursor-do nct USE me retC'T, --- key. Cty own State Zip Code 47=11 2. System Owner: r� ! �etTle Address(if different from location) C-.Town State Zip Code Telephone Number B. Pumping Record Date of Pumping pate 2. Quantity Pumped: - Gallons 3. Component: ❑ Cesspool(s) ^Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): - 4. Effluent Tee Filter present?y Yes ❑ No If yes, was it cleaned? Yes ❑ No 5. Observed condition of component pumped: Y V 6.✓V�cJ� 6. System Pumped By: Dave Tiney Mass 1AA95E Name Vehicle License Number Bateson Enterprises Inc Company — - - 7. ion where contents were disposed: GLS Signatu o au r Date Signature of Receiving Facility(or attach facility receipt) Date _ t5form4.doc• 11/12 System Pumping Record•Page 1 of 1