HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 203 MILL ROAD 5/5/2023 'Lx Commonwealth of Massachusetts
City/Town of �ECEtvEa
System Pumping Record
APR 2 5 2023
Form 4
TOoWN OF NoNYH ANNDOV R
DEP has provided this form for use by local Boards of HealiINLCgbM•ttQfW ay 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: fir n ack side rear Ciright
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ? •
use only the tab J
key to move your dress /
cursor-do not
use the return key. City/T� —� State Zip Code
2. System Owner:
r o P7
Name
umin r
Address (if different from location)
City/Town . Stag Zip C de
i
Telephone Number
B. Pumping Record
1. Date of Pumping D to 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4• Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
V�
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 H uler Date
Signature of eceiving Facility(or attach facility receipt) Date
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