HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 455 CHESTNUT STREET 4/3/2023 �ECEtV�D
Commorrwealth of Massachusetts
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System Pumping Record WOOF�; `
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EEP ras prawbed this 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
at Headth to determine the form they use. The System Pumping Record must be submitted to
lie kxal Board&Health or other approving authority within 14 days from the pumping date in
accordance wti 310 C M R 15.351. -
HOUSE: front back side rea left right
A. Facility information BUILDING: front back side rear left right
Important Yid
DECK: under
filling out `- System Location:
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key. Cty�Tovm State Zip Code
2 System Owner:r r�
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�.. Address(if different from location)
CityrTown State Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping Date z 2. Quantity Pumped: Z��
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:
6. System Pumped By:
Dave Tiney _ Mass 1AA95E _
Name vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ion where contents were disposed:
GLSD
Signature of Hauer Date
Signature of Receiving Facility(or attach facility receipt) Date
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