HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 285 REA STREET 7/1/2024 -"� Commonwealth of Massachusetts
City/Town of ���
a �o ti1 ti aS System Pumping Record p�
F o r rY-i ���4 ,A
PEP has provided this form for use by local Boards of Health, Other forms may,,, but the
information must be substantially the same as that provided here. Befor"eliRg11his form, check with your
local Board of Health to determine the form they use. The System Pumpi 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 side rea left right
A. Facility Information BUILDING: ont back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 1
use only the tab Z�-S ae,
key to move your Address
cursor-do not 0 �Qlrq/ MA
use the return Cit !Town
key. y State Zip ode
2. System Owner:
Name
rekm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ff
7 Date 12'1 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 com onent pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle license Nu ber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GLSD
1��12 7
Sign tune of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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