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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 DUNCAN DRIVE 10/24/2023 <LN Commonwealth of Massachusetts N City/Town of Nu a ` System Pumping Record N✓ ti4���3 Form 4 ©C 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 Inforl�ront Le , Left/Right rear of house, Left/Right side of house, Under[ filling f:When Left/Right side of building, Left/Right front of building, Left/Right rear of building, filling out forms 1. S ste Location: g g g on the computer, �� use only the tab ' v key to move your A dress // (/ r cursor-do not K—f-0� _ MA ! J use the return City/Town State Zip Code key. 2. �Iq tem�Owner• � ,� Name rmm ' Address(if different from location) MA City/Town Stat -Zjp ode Telephone N mber !L7 B. Pumping Record 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: A., 6. System Pumped By: Dave Tiney _ _ _. Mass F5821 A4 9 Name Vehicle Lic Bateson Enterprises, Inc. Company 7. Loc where contents were disposed. GLSD Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1