HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 4/3/2023 Commonwealth of Massachusetts
N City/Town of
System Pumping Record Rp� �o23 Y
Form 4 NOAt1��MEN1
WN OF p�ppA
DEP has provided this form for use by local Boards of Health. Other i6A 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 CMR 15.351. - - -
HOUSE: �frontk side rear left right
A. Facility Information BUILDING: k side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer, 9
use only the tab
key to move your Address (
cursor-do not ^
use the return N• f�'nC6UV ----- ---- - - (y�-- --- 1 CL
/Town
key. Cit y State Zip Code
2. System `Owner:
VQ t-oVX G k
Id Name
rnwn
Address(if different from location)
— -- --
City/Town . State Zip Code
Ct4j� 14C,- 221
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 o component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLS
T1�.3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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