HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 21 EASY STREET 4/3/2023 ConxnlofTwealth of Massachusetts �AECSI'10
- City/Town of
System Pumping Record x
Fowr .a
form for use by local Boards of Health. Other forms may be used, but the
=-E imug be substantially the same as that provided here. Before using this form, check with your
_ _ _ _==�saRt►to determine the form they use. The System Pumping Record must be submitted to
4, ea#th or other approving authority within 14 days from the pumping date in
CMR 15.351.
HOUSE: front back side rear le right
AL Facility information BUILDING: nt back side rear left right
Important VWh= DECK: under
filling tDc�d 1- S+= Location:
on use� 2-1 S�
key to move yes Adcress
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cursor-do r4tZ _—
use the ret"
key. C /Torrn State Zip Code
2- System Owner:
Marne
Address(if different from location)
-- --------- -- —
CWTown State Zip Code
919- q 4s - az2
Telephone Number
B. Pumping Record
1. Date of Pumping 3h) 2,3 — 2. Quantity Pumped: �S
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - / --
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of c mponent pumped:
Nof Mc,�
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ion where contents were disposed:
GLS
Signature f uler Date
Signature of Receiving Facility(or attach facility receipt) Date
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