HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 GRAY STREET 7/1/2024 jy�c
Commonwealth of Massachusetts
- City/Town of _ Ttib
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System Pumping Record
Forni 4 �
DEP has provided this form for use by local Boards of Health. Other forms maay beta ed, but the
information must be substantially the same as that provided here. Before I iS 6 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 side rea le . right
A. Facility Information BUILDING: ront back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 2(3�-
key to move your Address
cursor- not dl?s MA
use the return
urn City/Town
key. Slate Zip Code
roc
2. System Owner:
Name
roan
Address (if different from location)
MA
Clty/Town Slate Zip Code
3c7"7 246
Telephone Number
B. Pumping Record isod
1. Date of PumpingL
Date ( 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 con ition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E a�1AD31
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Nation where contents were disposed:
� 61,3 zy
Signature of Hauler Date
Signature of Receiving Facility(orrattach facility receipt) Date
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