HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 4/25/2023 AECE,tvEG
Commonwealth of Massachusetts �2023
City/Town of pPR 2 ovER
System Pumping Record -`OWNOTHDEggk MEtJ
Forni 4 HE
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:Qfrornt back side rear left ht
A. Facility Information BUILDING rig back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 11'L
use only the tab
key to move your Address
cursor-do not N Afk �
key.
use the return City/Town -�`��' State Zip Code
2. System Owner:
pnS I
Name
rcmin
Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3 2. Quantity Pumped: l�)
uany p Date 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. a on where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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