HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 CRICKET LANE 11/27/2023 Commonwealth of Massachusetts
City/Town of v�r
a System Pumping Record `� �tipti3
Form 4
N
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 bac side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, � CC1G\ \ 1
use only the tab 2
key to move your AddressA
cursor- not f'�1�d�1� MA
use the return
urn City/Town
key. State Zip Code
Q2. System Owner:
I" `
Name
etun
Address(if different from location) .
_ MA
Citylrown State Zip Code
LI&- 13 &s
Telephone Number
B. Pumping Record
II
1 Date of Pumping Date 1 --- 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 put
ed:
1Ja r r�s
6. System Pumped By:
Dave Tiney Mass 582 Mass 1AA95E
Name Vehicl Licens umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
LS
1- Tr
Signature f Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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