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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 LOST POND LANE 5/2/2023 RECENE6 I�IN_ Commonwealth of Massachusetts City/Town of & ��2023 System Pumping Record pFNORYHANDOtEF ' TOWN F t pEpARTMEN Form 4 HEAD 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. HOUSE: fron back side rear left right A. Facility Information BUILDING: front back side rear left right DECK: under Important:When filling out forms 1. System Location, on the computer, use only the tab key to move your Address cursor-do not I rt SC - In A4 �'�5- use the return City/Town C St Ate l Zip Code key. 2. System Owner: Name mwn Address (if different from location) City/Town . Slate Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: 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 conditi n of component pumped: Ot' 6. ' System Pumped By: Dave Tiney Mass 1AA95E Name Vehicle License Number Bateson Enterprises Inc Company 7. lion where contents were disposed: LSD y 2� Z� Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Dale 15form4.doc• 11/12 System Pumping Record •Page 1 of 1 I��