HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 110 FULLER ROAD 7/1/2024 Commonwealth of Massachusetts
City/Town of As� `
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i° System Pumping Record �° �Ql�oti�
Form 4
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DEP has provided this form for use by local Boards of Health. Other forms a.a �..I�d,�ut the
information must be substantially the same as that provided here. Before iris form, check with your
local Board of Health to determine the form they use. The System Pumpinb'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 �baPkside rear leftVrightA. Facility Information BUILDING: frontside rear left
Important:when DECK: under
filling out forms 1. System Loca i��n:
on the computer, 1 1 /�
use only the tab 1 1 0
key to move your Addres
cursor•do not use the return t� ( ��L,,�- MA Q
key. City/Town Slate Zip Code
tab 2. System Owner:
Or, r 2
Name
rn�m
Addreas(if different from location)
MA
cityrrown State Zip Code
Telephone Number
B. Pumping Record
o L
1. Date of Pumping Date'
2 N 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
i
6. System Pumped By:
Dave Tiney Mass 1AA95E =1AD31
Name Vehicle license Numb r
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD
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Signature of Hauler Dale
Signature of Receiving Facility(orahach facility receipt) Dale
l5form4.doc• 11112 System Pumping Record •Page 1 of 1