HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 SHANNON LANE 4/3/2023 Commonwealth of Massachusetts ilscENE0
t City/Town of
w� System Pumping Record
Form 4vo of
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DEP has provided this form for use by local Boards of tj
Health. OtheitwrTP1"Hm}ay 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: Pront
back side rear left ri ht
A. Facility Information BUILDING: back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab IS S�"Ano ' I�
key to move your Address —
cursor-do not +N,
use the return "_- �n Q 0If &__CX_
key. City/Town State
Zip Code
2. System Owner:
Qlc w(4 touj(L
Name
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Address(if different from location) --
City/Town . State Zip Code
_ z t 9
Telephone Number
B. Pumping Record
1. Date of Pumping Date�� 2. Quantity Pumped: Asa
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:
X) r. , k
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
GLSD
Signal e f Ha r Date 1
Signature of Receiving Facility(or attach facility receipt) Date
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