HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 976 TURNPIKE STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
{ Form 4 JUL
0 3 2023
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 System 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: front ack side rear eft ri,
A. Facility Information BUILDING: front ba.c side rear left ril
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, Rr'Cp
use only the lab
key to move your Address
cursor-do not
use the return City/Town Slate Zip Code
key.
2. System Owner:
Name
nmin
Address (if different from location)
Clly/Town . State Zip Code
C
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons��
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Traf
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
I 5. Observed condition of component pumped: /
i
I
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
i
7. L ion where contents were disposed:
GLS
Ig 12,3
Signature of Hauler Dale
t
Signature of Receiving Facility(or attach facility receipt) Date
IStorma.doc vi 2 System Pumping Record -Page
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