HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 LONG PASTURE ROAD 5/2/2023 Commonwealth of Massachusetts RECEIVE[)
City/Town of
x System Pumping Record 2023
Form 4
TOWN OF NORTH
ER
DEPARTMENT
FF
DEP has provided this form for use by local Boards of Health. OtnZArTorms 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 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: front bac side rea 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 lab fe—
key to move your Ad7rress,
cursor-do not
use the return
P.
key. City/Town Stale Zip Code
2. System Owner:
.e tC
Name V
lNWO
Address (if different from location)
Cily/Town . Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1zC&3 2. Quantity Pumped: �s
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. Observedd )conditio of component pumped:
6. ' System Pumped By.
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Ln where contents were disposed:
(G3LS
Signature of Hauler Date
t
Signature of Receiving Facility(or attach facility receipt) Date
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