HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 104 SHERWOOD DRIVE 5/8/2023 7
� Commonwealth of Massachusetts VESCSVE®
w City/Town of �1
System Pumping Record MPS � �N®CNS'K
{ Form 4 of NQ � SMEN�
t ��rtM VSP
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 yo
local Board of Health to determine the form they use. The Syste.m Pumping.Record must be submitted
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 rig
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important,When
filling out forms 1. System Loc tion:
on the computer,
use only the lab
key to move your Address
cursor-do not
use the return City/Town State"` Zip Code
key.
2. System Owner:
J-Shc.rt`
Name
/Ilmn r
Address (if different from location)
City/Town . Slate ZI Code
ci
Telephone Number
B. Pumping Record
1. Date of Pumping Z 2 Quantity P
Date 3 , uany umped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 4 No 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. ntion where contents were disposed:
Signature of Hauler
Date
Signature of Receiving Facility(or attach facility receipt) Date
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