HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 102 SPRING HILL ROAD 10/24/2023 Commonwealth of Massachusetts
w City/Town of �ti0'1
o System Pumping Record OC��
w Form 4
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 sid rear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
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use the return ity/Town State Zip Code
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2. S tem Owne�y" Y"
ame
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Address (if different from location)
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City/Town State .�/ �}�'N' ,Zip Code
Telephone Number
B. Pumping Record /
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1 Date of Pumping '" � 2. Quantity Pumped: Gallons
ns
ate
3. Component: ❑ Cesspool(s) Septic Tank ElTight Tank Eldrease Trap
❑ Other (describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned es ❑ No
5 Observed condition of com o ent pumped,
6. System Pumped By:
Dave Tiney Mass F582 �1AA951
Name Vehicle Licen Number
Bateson Enterprises, Inc.
Company
7. Location wherLcoents were disposed:
GLSD
i
. i
Signature Ha Wr Dat
Signature of Receiving Facility(or attach facility receipt) Date
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