HomeMy WebLinkAboutTight Tank - Septic Pumping Slip - 1429 OSGOOD STREET 4/3/2023 (3) t-tECEtVEG
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Commonwealth of Massachusetts
City/Town of
System Pumping Record ,HANOO��
� Form 4 TO�HE�TH QapPBTMENT
DEP has provided this form for use by local Boards of Health. Other forms 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: ront ack side rear le t
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. S�Ste Location-
on the computer, `/,/ /Q% /�'IY/J
use only the tab
key to move your Ad re `�%`,,. � �
cursor-do not
use the return Cit /Town
key. y State Zip Code
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2. System Owner:
Name
remm r '
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date �3 2• Quantity Pumped: Gallons
G
3. Component: ❑ Cesspool(s) ❑ Septic Tank 'r—�Tight Tank g ❑ 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. Location where contents were disposed:
GLSD
Signature of Ha
Date
Signature of Receiving Facility(or attach facility receipt) Date
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