HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 SHERWOOD DRIVE 4/25/2023 'Lx Commonwealth of Massachusetts REcelvED
City/Town of
a System Pumping Record
Form 4
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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: front back side rear le right
A. Facility Information BUILDING; rout back side rear left right
Important:When DECK: Under
filling out forms 1. System Loca ion:
on the computer,
use only the lab to e�Woc��
key to move your Address
cursor.do not Wit-
key.
use the return City/Town St to Zip Code
2. System Owner:
z" L;
Name
rHwn '
Address (if different from location)
City/Town . State Zip Code
G63-3?o-Sots-
Telephone Number
B. Pumping Record
1. Date of Pumping L Date A- 2, Quantity Pumped: � J
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes `r No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Por
Mal
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ion where contents were disposed:
� ylsl�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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