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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 252 GRAY STREET 12/21/2023 Commonwealth of Massachusetts City/Town of F System Pumping Record pE 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 left Igh A. Facility Information BUILDING: front back side rear left right Important:When DECK: under filling out forms 1. System Location: on the computer, L� Grp, use only the tab �� y' key to move your Address cursor-do not ii ii N^ © I use the return Iv " ` MA key. City/Town State Zip Code Q 2. System Owner: f t e Cc— Name Address(if different from location). MA City/Town State Zip Code t42�S Telephone Number B. Pumping Record 1. Date of Pumping -'Z 1 p g �Date � 2� Quantity Pumped: CI;' 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 pu ped: 6. System Pumped By: Dave Tiney Mass F5821 Mass 1AA95 Name Vehicle License N ber Bateson Enterprises Inc. Company 7. Liacation where contents were disposed: GLS Ills- 3 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1