HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 SULLIVAN STREET 7/3/2023 :_C_\ Commonwealth of Massachusetts
City/Town of
.z System Pumping Record 03TO
Form 4 �V
DEP has provided this form for use-by local Boards of Health. Other forms may 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.
A. Facility Information
1. System Location: rout of house, Left/Right rear of house, Left/right side of house, Left/
Right side of buiidleft ight front of building, Left/Right rear of building, Under deck
on the computer, Q
use only the tab
key to move your Address -
cursor-do not `
use the return O - _ MA 1
key. Ci y/Town State Zip Mde
2.
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Name -- ---- -
rarm
Address(if different from location)
MA
City/Town State Zip Code
C t
Telephone Number
B. Pumping Record
1. Date of Pumping --s��v --- 2. Quantity Pumped: —
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): -- --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condJ.' r
of component pu ped:
IJ4 �^ — -- - - -- — --
6. System Pumped By:
David Tines Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. rnion where contents were disposed:
CW
owell Waste Water
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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