HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 NORTH CROSS ROAD 9/21/2023 Commonwealth of Massachusetts
City/Town of
a
System Pumping Record ��F� ltip'L3
Form 4 ce ti
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 ac side re le right I
A. Facility Information BUILDING: front back side rear eft right €
Important:When DECK: under
filling out forms 1. System Location:
on the computer, f.f ��-�� CfoSS Q� 1
use only the tab
key to move your Address d
cursor-do not ��� MA 1 FiLi�
key. _
use the return Cii`ty'lrown Slate Zip Code
i
rd
2. System Owner:
Name
wrtm
Address (if different from location)
MA - I
CityfTown State Zip Code
2 S3
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped
Date Gallons
3. Component: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): / -
k
4. Effluent Tee Filter present? ❑ Yes �] No If yes, was it cleaned? ❑ Yes ❑ No
/ F
5. Observed condition of component pumped:
bJa�ram.
6. System Pumped By:
ii
Dave Tiney Mas F5821 Mass 1AA95E 1
Name VehiclkQELnw4umber "
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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