HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1459 TURNPIKE STREET 7/29/2024 Commonwealth of Massachusetts
City/Town of UL 2 g Z0Z4
- J
a System Pumping Record
Forni 4 t,ent
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 side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
he tab, /� `Q``(
use only the tab �s� burn 1�`
key to move your Address
cursor-do not / A MA
use the return
key. CitylTown State Zip Code
2. System Owner: 4
Name
iaan —
Address (if different from location)
MA
Cltyrfown State Zip Code
01g9- nI -75`(y
Telephone Number
B. Pumping Record /CPC
1. Date of Pumping Dace 2 2 `t 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:
�Of MS I
6. System Pumped By:
Dave Tiney Mass 1AA95 M�1AD3
Name Vehicle License N r
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
Ci
S
6lZ�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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