HomeMy WebLinkAbout- Septic Pumping Slip - 80 LOST POND LANE 5/2/2023 'Lx Commonwealth of Massachusetts RECEIVED
w City/Town of tjAA 022023
System Pumping Record
Form 4 TOHEALLTH DEPARTMENT
WN OF NORTH ER
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 System 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 back side rear eft fight
A. Facility Information BUILDING: front back side rear left right
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2. System er:
Z4+mv D
Name
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Address(if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record I/_ ?
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --
4, Effluent Tee Filter present? ❑ Yes o 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. Location where contents were disposed:
GLSD
Signature of Ha er Date
Signature of Receiving Facility(or attach facility receipt) Date
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