HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 720 FOSTER STREET 7/21/2023 L\- Commonwealth of Massachusetts ���``� -rA
= City/Town of ore �1
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System Pumping Record
Form 4
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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.
A. Facility Information
Left/Right front of house, Left/ Right rear of house, Left/ ig t ide of house, Under C
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/Right front of building, Left/Rig t rear of building,
on the computer, Zv I _W.� Sl
use only the tab h 1
key to move your Address `�� �,A
cursor.-do not U MA
use the return City/Town State Zip Code
key.
2. System Owner:Gel I SA%('Nrh6
Name
Address(if different from location)
MA
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gauons
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 condition of component pumped:
p'),'.
6. System Pumped By:
Dave Tiney Mass 582 1VAA 1,4119 5Q
Name Vehicle umber
Bateson Enterprises, Inc.
Company
7. L tion where contents were disposed
(GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
i
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