HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 HILLSIDE ROAD 10/2/2023 ,C\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 0
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 Right side of house, Undf
Important:When Right front of building,/ Ri building, le
Left/Right side of Left , Left building,
/Right rear of buidin
filling out forms 1. System L cation: g g g g g g
on the computer, Mst use only the tab
key to move your "'�A dress
cursor-do not MA Q i &�iS
use the return City/Town State Zip Code
key.
2. System Owner:
,eb
Name
mum _
Address(if different from location)
MA
City own State�'+�—� Zip Code
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Telephone Number
B. Pumping Record
C-1'1" �-- 2. Quantity Pum e&
1. Date of Pumping y »Date Gal ons
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
i
5. Observed condition f component pumped:
W1 -
6. System Pumped By:
l Dave Tiney Ma F582 //{�,ya /A,#9-5Q
Name Vehicl ' en umber
Bateson Enterprises, Inc.
Company
7, ion where contents were disposed.
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GLSD
-- 9)-Z 7
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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