HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 DUNCAN DRIVE 1/2/2024 Commonwealth of Massachusetts
= City/Town of
- System Pumping Record
a �
Form 4
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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 ide rear left rig,
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms' 1. System Location:
on the computer,
use only the tab Ks nc",;j. 00"
key to move your Addres
cursor-do not 1 x dt MA �
use the return CitylTown State Z I
key.
Code
2. System wner:
I
/1 -SIC �o^
Name
rerun
Address(if different from location).
MA
City/Town State Zip Code
s /
Telephone Number
B. Pumping Record
1. Date of Pumping Dai2'I& 3 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - - — -
4. Effluent Tee Filter present? ❑ YestNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component ped`
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6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA9
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7, ion where contents were disposed:
GLSD
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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