HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 301 RALEIGH TAVERN LANE 8/26/2024 Commonwealth of Massachusetts
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City/Town of `� Otis
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System Pumping Record
Form ,4
DEP has provided this form for use by local Boards of Health. Other forms may bte tasbut 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 -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front ack 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,
use only the tab 3 c *"'
key to move your Address
cursor-do not L� MA 91/
use the return Cll !Tow � a l _17
n
key. y State Zip Code
2. System Owner:
rd
dt
r
Namee
idan
Address (if different from location)
MA
City/Town Slate Zip Code
,C I & r`C&("-oZgQ
Telephone Number
B. Pumping Record
1, Date of Pumping Date 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:
PM
6. System Pumped By:
Dave Tiney ass 1AA95E Mass 1AD31Z
Name ehicle License Num r
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
LS
�it�ILA
-SignaturV of Hauler Dale
Signature of Receiving,Facility(or attach facility receipt) Date
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