HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 LACY STREET 7/3/2023 Comnilonwealth of Massachusetts
City/Town of N��✓�NOE
System Pumping Record U` p32�Z3
Form 4 ,
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
local Board of Health to determine the form they use. The Syste.m Pumping.Record must be submittE
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 ri
A. Facility Information BUILDING: t ba.ck side rear left ril
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, CZ
use only the lab
key to move your Address
cursor•do not W , AnJd��-
use the return Ci y/Town State Zip Code
key.
2. System Owner:
ub �
r
c4 Se
Name
eimn
Address(if different from location)
City/Town . Slate Zip Code
`1 -� z,33-9-`f,Z
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Dale Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trat
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes El No
5. Observed condition of component p mped:
QW MCA
6. System Pumped By:
Oave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. tion where contents were disposed:
GAS
air
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc• 11/12 System Pumping Record -Page