HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 742 WINTER STREET 7/3/2023 LN Commonwealth of Massachusetts
City/Town of N�'c:aaR�crF
System Pumping Record t�EP�"� o31p'L3
{ Form 4 IOU
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: front ack side rear le ri;
A. Facility Information BUILDING: ont back side rear left ril
DECK: under
Important:When
filling out forms 1. System Location: r^�,
on the computer, t� /` .W�A'
use only the lab V r
key to move your Address
cursor.do not -ty\c y �1� /� i C6C4<
use the return Clly/Town Stale-` Zip)Code
key.
2. System Owne :
ub
r
6( \Cc, Ctt*�
Name
man '
Address (if different from location)
Cily/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Dal �' 2. Quantity Pumped: cauo�ns0 --
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease TraK
❑ Other (describe): -- —
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
ocx
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
i
7. nation where contents were disposed:
(A� (n 1q 7o
Signature of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Dale
t5form4.doc t t/t 2 System Pumping Record•Page
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