HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BARCO LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record 2023
{ Forma
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 ear left D
A. Facility Information BUILDING: front back side left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, /
use only the lab f rl►�` !ti
key to move your A /A) /�� `/ �// ��
cursor-do not (A�[JJ !�//rl�-
use the return
key. City/Town State Zip Code
2. Sy t Owner:
Q
Name
arum '
Address(if different from location)
City/Town . St zip��` Z�ode
Telephone Number j
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --
4, Effluent Tee Filter present? ❑ Ya,5-<N0 If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents f re disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc 11/12 System Pumping Record•Page 1 of 1