HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 BROOKVIEW DRIVE 4/25/2023 RECEIVED
<C.\- Commonwealth of Massachusetts
City/Town of APR 2 52023
a TOWN OF NUh I n ruvr,3OV€R
System Pumping Record HEALTH DEPARTMENT
Form 4
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 Syste.m 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: ron back side rear le right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab � �('��U� �C
key to move your Address
cursor-do not
use the return Cit ___ __ _ V
key. yown State Zip Code
2. System Owner:
Name
auxn
Address(if different from location)
City/Town State
Zip Code
9 714-t5r, fl'32ox
Telephone Number
B. Pumping Record
1. Date of Pumping Da �3L 2. Quantity Pumped: /9
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:
N
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc tion where contents were disposed:
GLS
g13I7;
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record•Page 1 of 1