HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 59 NORTH CROSS ROAD 6/10/2024 i Commonwealth of Massachusetts 61t 01khwnaovet
w City/Town of N l 0 2024
a System Pumping Record JU
Form 4 m t
% cA e�
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: iron back de rea le right
A. Facility Information BUILDING: front side rear a right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, C, /( � (y
use only the tab ` V" \�� ��
key to move your d res
cursor-do not MA
use the return it !Town
key. y State Zip Code
,.n
2. System Owner:
U CIA IN C
Name
/BNY/I
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallo s
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
f
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yest No If yes, was it cleaned? ❑ Yes ❑ No
5. Obdse��rved co dition of component pumped:
N
6. System Pumped By:
Dave Tiney Mass 1AA95E Mas�lAiz
Name Vehicle License Numb r
Bateson Enterprises, Inc.
Company
7. Loqkicn where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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