HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ORCHARD HILL ROAD 7/3/2023 � Commonwealth of Massachusetts
u 6 City/Town of
System Pumping Record ��� 03202
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 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 CM 15.351. -
HOUSE: fro ack side rear left right
A. Facility Information BUILDING: fron back side rear le righ
Important:When DECK: under
filling out forms 1. System L cation,
on the computer,
use only the lab
key to move your dd ss Jai
cursor-do not
use the return key. City/Town State Zip Code
2. Sotem wn
ame
rerwn
Address (if different from location)
City/Town . State,,, - Zip Code
Telephone Number
B. Pumping Record
sc �� 3
cam/
1. Date of Pumping 2. Quantity Pum ed:
Date y p Gallons
3. Component: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumpe .
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where con fA,nts were disposed:
GLSD
Signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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