HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 167 DUNCAN DRIVE 5/13/2024 P.Ur j
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Commonwealth of Massachusetts
City/Town of MAY 13 2024
System Pumping Record
Form 4k:
M
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: fron >back side rear le ri
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 J//r7 (�
to`- (/%.nc_"'
key to move your Address
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
�C � s►�:
Name
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Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
2
1. Date of Pumping Date - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) (� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): J
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pumped:
06rm tI
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD3 _
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
r
h 2�
Signature of Hauler Date
Signature of Receiving, acility(or attach facility receipt) Date
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