HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 MILL ROAD 5/2/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of _ rn�Y 022023
a System Pumping Record TO\0OFNoFk ANDN
Form 4
HEALTH DEPARTMENT
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 tc
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. -
Ho USE: front 0 side rear left QrighA. Facility Information BUILDING: front back side rear left
DECK: under
Important:When
filling out forms 1. System Location: 1
on the computer, �/ (J �r ,) 2
use only the lab �Q 1 _
key to move your Address 1,� 4
cursor-do not � An(-%o ve I r _ M el k y\r
use the return City/Town Stafe Zip Co-de
key.
2. Sy tem Owner: p
W
Name
rrran
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
41WUL3
1. Date of Pumping Date 2. Quantity Pumped: Gallon
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. Wcation where contents were disposed:
nGLS
09CL zz 37
Signature of er Date
Signature of Receiving Facility(or attach facility receipt) Dale
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