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
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