HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 SOUTH CROSS ROAD 1/23/2024�; o�h Aodo�er
Commonwealth of Massachusetts down ®fib
N City/Town of 3 2024
a
System Pumping Record BAN
-Form 4 amerlt
Delp
' DEP has provided this form for use by local Boards of Health, Other form e�useed, 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 bac si�Ieft
A. Facility Information BUILDING: front back
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 9 � CUSS use only the tab L 6u. "\
key to move your Address
cursor-do not MA
use the return Cit /Town
key. y State Zip Code
2. System Owner:
C./Cv, GeA c CIr\
Nam
Address(if different from location).
MA
City/Town St ,t�� _/ Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 2. Quantity Pumped:
c
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g [] Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observe ond'tion of component pu ped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License N tuber
Bateson Enterprises, Inc.
Company
7/ ion where contents were disposed:
GLS -!
Signature of Hauler Date
'a
Signature of Receiving Facility(or attach facility receipt) Date
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