HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 329 REA STREET 11/21/2023 Commonwealth of Massachusetts
f
City/Town of
System Pumping Record NOVA
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 Infor iation
Left ight front of house, Left/Right rear of house, Left/Right side of house, Under[
Important:When
filling out forms 1. System Locatio /Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab
key to move your Add s
cursor-do not MA v!
use the return ityrrown j I ol State Zip Code
key.
2. System Owner:
)1 dV6
game
Address(if different from location)
MA
CitylTown State 505 1
L'I �Zip Code -- ---
Telephone Number
B. Pumping Record ez�_
Quantity Pum ed:
1. Date of Pumping Date y p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
6. System Pumped By:
Dave Tiney - Mass F5 1 MA
}�
Name Vehicle Lic umber
Bateson Enterprises, Inc.
Company
7. Loca where contents were disposed:
D
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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