HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 BRIDGES LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
a `
System Pumping Record
Form 4 ` Q31023
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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
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: ont ack side rear left
A. Facility Information BUILDING: front back side rear left ril
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, -tJ j q SC',& ej A
use only the lab l
-----------------------------
key to move your Address
cursor-do not N, /�A > (_ ML 0
use the return City/-ro/wnn` 1 Stale Zip Code
key.
2. System Owner:
qb 1
Name
rrwin '
Address (if different from location)
Cily/Town . State Zip Code
Telephone Number
B. Pumping Record
3 f�c
1. Date of Pumping 64Date — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tral
❑ 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:
GLSD
Signature of Nuler Date
Signature of Receiving Facility(or attach facility receipt) Date
15(ormel.docr 11/12 System Pumping Record Page