HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 5/2/2023 Y
-L*"\ Commonwealth of Massachusetts RECENED
w City/Town of
System Pumping Record -THi400Form 4 'TOWN OTH DEPAR METE
HEAL
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 ye
local Board of Health to determine the form they use. The System Pumping.Record must be submitted
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 CDlside rea le righ
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important:When
filling out forms 1. System Location
on the computer,
use only the lab aV �f
key to move your Address
cursor-do not
use the return
key. City/Town State Zip Code l
2. System wner:
.�
r
Name
erwn
Address (if different from location)
City/Town . State Zip Code
CR;s-F-K -kg 3
Telephone Number
B. Pumping Record
1. Date of Pumping Dale Z 2. Quantity Pumped:
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:t
M.
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lxation where contents were disposed:
GLSD
n� yl26l�
Signatur auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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