HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 168 CAMPBELL ROAD 11/21/2023 Commonwealth of Massachusetts
City/Town of 11p23
a System Pumping Record �l0�
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 sad rear left hht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, �j� - � � I I fJ
use only the tab Jlp nQ l g`
key to move your Address 1�
cursor-do not ,( ) Cdll�/
CK-
use the return ` MA Q(�
key. City/TownState Zip Code
2. S stem Owner:
e?'� c�San i4
Name
nrem �L
Address(if different from location)
MA
City/Town State
Zip Code
yr<<-ylSr ZBas _
Telephone Number
B. Pumping Record
1. Date of Pumping �f!( L - U
p g Date 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 condi *on of component pumped:
J106r roc.
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicl cen umber
Bateson Enterprises, Inc.
Company —
7. Ltionere contents were disposed:
GLS
Signature of Hauler Date
----------- -----------
Signature of Receiving Facility(or attach facility receipt) Date
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