HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 230 GRANVILLE LANE 9/1/2023 Commonwealth of Massachusetts
u City/Town of
a
System Pumping Record
Form 4 O�
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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.
HOUSE: front back ide rear left arigh
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, .� q
use only the tab
key to move your Address
cursor-do not N An MA c)
use the return key. City/Town State Zip Code
2. System Owner:
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Name -- -
nnm
Address(if different from location)
MA
Cityrrown State Zip Code
-)4C,o
Telephone Number
B. Pumping Record C
1. Date of Pumping Date 2. Quantity Pumped. 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 condition of component pumped:
orN.c,
6. System Pumped By:
Dave Tiney Mass F5821 ss 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
LS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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