HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FULLER ROAD 1/2/2024 Commonwealth of Massachusetts
City/Town of ot
System Pumping Record N+
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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: (Z�
r eft right
A. Facility Information BUILDING: back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, (; r- ��(I
use only the tab —1 (- 2f
key to move your Address
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use the return
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key. CitylTown State
Zip Code
2. System Owner:
«��'e 0 'z VoLkr
Name
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Address(if different from location) .
MA
City/Town State
Zip Code
Q -q2.3-
Telephone Number
B. Pumping Record
1. Date of Pumping t Date
Za 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 condition of component pumped:
d Y'r-N C
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nu ber
Bateson Enterprises Inc.
Company
7. ion where contents were disposed:
GLS
0 I2.�20�2.3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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System Pumping Record•Page 1 of 1
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