HomeMy WebLinkAbout- Septic Pumping Slip - 150 JOHNNY CAKE STREET 5/2/2023 RECEIVED
Commonwealth of Massachusetts
City/Town of _ Um 022023
w° System Pumping Record NA OEFTH , i ► +
Forrii 4 Tf}HE
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 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: front ac side rear le ri h
A. Facility Information BUILDING: front back side rear left rig
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 ti - 1n
use the return key. Ci�own Slate Zip Code
2. System Owner:
�N
Name
Address(if different from location)
City/Town . Slate Zip Code
771 J7n
Telephone Numb%r
B. Pumping Record
1. Date of Pumping Dale 1�6�_
2. Quantity Pumped: G uQns��
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter presents Yes ❑ No If yes, was it cleaned? ❑ es ❑ No
5. Obse ed condition f component pumped:
6. " "System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo where contents were disposed:
Signature of Hauler OeL
Signature of Receiving Facility(or attach facility receipt) Dale
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