HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 160 FARNUM STREET 10/30/2023 Commonwealth of Massachusetts No�p o�3
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a System Pumping Record 0
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 side rear(a right
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out forms 1. System Location:
on the computer, /� el
use only the tab �Ir) V4 n aA( ,
key to move your Address
cursor-do not _ MA _
use the return Cit /Town State Zip Code
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key. y
2. System Owner:
„n fin
Name
rtnm
Address (if different from location)
_ MA ____
Cityrrown State .Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 3--- 2. Quantity Pumped: Gall/nsx,
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:
++
6. System Pumped By:
Dave Tineses __ M ss F5821 Mass 1AA95E
Name Ve icie License umber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLS
c
h?
Signatu e 6T Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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