HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 HOLLOW TREE LANE 5/8/2023 7 �EQEtVEG
Commonwealth of Massachusetts
City/Town of rc�Ay p g1023
System Pumping Record NOFNpA�dD�E�`
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Form 4 �O �TN
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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: front back side re �erigh
righ
A. Facility Information BUILDING: ba.ck side rear
DECK: under
Important:When
filling out forms 1. System gLa
:on the computer, //T
use only the lab "� ) ')�
key to move your Address
cursor•do not �� Of&' (c
use the return City/Town State Zip Code
key.
2. System Owner:
,c tin
Name
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Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dale Z 2. Quantity Pumped:
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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ��on where contents were disposed:
GLS ON
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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