HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 322 BOSTON STREET 9/21/2023 Commonwealth of Massachusetts t
= City/Town of
System Pumping Record �o���R tioti3
Form 4 0 ti1
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 - ZD
HOUSE: front back ide rear left A. Facility Information BUILDING: front side rear left I
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, 3 7-2 �ys J1 t
use only the tab
key to move your Address
cursor-do not P , PA-t' MA
use the return Cityfrown Slate Zip Code
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2. System \Owner: \-
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Name
Bnm
Address(if different from location) a
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MA
City/Town State 15
��ode �
Telephone Number t
B. Pumping Record
1. Date of Pumping Date G �L 2. Quantity Pumped: Gallons
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3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - --
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4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes ❑ No
5. Observed con ition of component pumped:
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6. System Pumped By:
Dave Tiney Mass nF5821 Mass 1AA95E y+
Name Vehicle Number ry
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
4
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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