HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 STILES STREET 8/26/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form "'
a yr
DEP has provided this form for use by local Boards of Health. Other forms may h-
, tt� he a
information must be substantially the same as that provided here. Before 'tbls tormocheck with your
local Board of Health to determine the form they use. The System Pumping Rll ecord 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:' ack side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, r
use only the tab /o
key to move your Address
cursor-do not
use the return MA G it y�
key. C lylTown Slate Zip Code
2. System Owner:
Name ----
morn
r
Address(if different from location)
MA
Cltyrrown Slate J _ Zip Code
') -
Telephone Number
B. Pumping Record cc
1. Date of Pumping Date Z 2. Quantity Pumped: /5W
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:
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD31
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
(ecot�n
LSD
Fs �2a I2 1
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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