HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 TUCKER FARM ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record ®31013
Form 4 wl
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 your
local Board of Health to determine the form they use. The System Pumping.Record must be submitted to
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 rear left �ghtt
A. Facility Information BUILDING: front back side r left
DECK: under
Important:When
filling out forms 1. S stem Location:
on the computer,
use only the lab
key to move your Addre s
cursor-do not -,M
key.
use the return Ity/Town Slate Zip Code
2. System Ow�INne/rpr-
W�
Name
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Address(if different from location)
City/Town . State � ��.� Z�Code
Telephone Number
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B. Pumping Record
,5-- /5-d
1. Date of Pumping Date 2. Quantity Pumped:
,�.� Gallons
3. Component: ElCesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
El Other (describe): \ - -----
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu ped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents re disposed:
GLSD
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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