HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 FULLER ROAD 6/10/2024 Commonwealth of Massachusetts
_ City/Town of N 1 p ZU4
System Pumping Record
Form 4
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 left rig
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Loc tlon:
on the computer, n
use only the tab ��� l�-
key to move your A dress
cursor-do not ./_"- 1�d,.,Q, MA ()I
use the return City/Town State Zip Code
key. P
2. System Owner:
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Name
ie�un
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Zf 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:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLS ------- -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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