HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 CAMPBELL ROAD 6/17/2024 ,rl1\0111t
Commonwealth of Massachusetts �`d �1
= City/Town of �� vi-N
System Pumping Record
er
Form 4
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: front back si rear eft right
A. Facility Information BUILDING: front back side left right
DECK: under
Important:When
filling out forms 1. Sy tem Lo ation:
on the computer, G,L
use only the tab
key to move your Ad r ss
cursor-do not 'M i'" MA V v�
use the return Cat /Town State Zip Code
key.
2. Systep Owner:
Name
rerun
Address(if different from location)
_ MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record Axj
7-Y1. Date of Pumping Da e — 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:
/110
6. System Pumped By:
Dave Tiney Mass 1AA95E 31Z
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD'
Signature of Ha r Date J
Signature of Receiving Facility(or attach facility receipt) Date
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