HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 317 RALEIGH TAVERN LANE 6/17/2021 Commonwealth of Massachusetts
----- City/Town of tioti�
System Pumping Record
a Form 4 'Cn�r
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: ron back side re left' right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, J n I
use only the tab / C� h
key to move your Add7;��W
//key. /1cursor-do not MA
use the return City/Town State Zip Code
2. S stem Owner:
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Name F2nX
Address(if different from location)
MA
City/Town State Zip Code 1 '152 3 Y6;1�;
Telephone Number
B. Pumping Record
115�3J
1. Date of Pumping Date 12. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 'A� 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 1AA95F�Mass 1AD31Z
Name Vehicle License N !
Bateson Enterprises, Inc.
Company
7. Loc ' where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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