HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 75 DUNCAN DRIVE 11/21/2023 Commonwealth of Massachusetts
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City/Town of -\'O
a System Pumping Record
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.
A. Facility Information
Left/Right front of house, Left Right ar of house, Left/Right side of house, Under[
Important:When
filling out forms 1. S t Location: Left/ Right side of building, Left/Rig t front of building, Left/Right rear of building,
on the computer, �j
use only the tab '—I`
key to move your 7-X—A
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cursor-do not 7N ` Ct�l MA k`7 _
use the return City/Town c State Zip Code
key.
2. Stem O ner:
Name
Address(if different from location)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record -d 7E
1. Date of Pumping Xp 2. Quantity p Pum ed.
p g Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — -- - -- - --- - _ -
4. Effluent Tee Filter present? ❑ Yesplo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F582 ANI A4
Name Vehicle Licen umber
Bateson Enterprises, Inc.
Company
7. 1-o here contents were disposed.
4G .
LSD
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Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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