HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 4/3/2023 (3) IC
Commonwealth of Massachusetts �IECENED
r City/Town of
System Pumping Record
Form 4 OVER
TC04 OF of%PXRT MTH EN7
DEP has provided this form for use by local Boards of Health. Other formsLmay 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: fron back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, q � n
use only the tab 1`
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code
IsD
2. System Owner: 1I
fC LLrA�X `'t e l J
Name
mwn r
Address(if different from location)
City/Town . State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3 1b
p 9 Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes P 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
Signa re of Haul ��1U I23
Date
Signature of Receiving Facility(or attach facility receipt) Date
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