HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 1030 FOREST STREET 8/26/2024 Commonwealth of Massachusetts ',�,�r�naw��
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City/Town of
System Pumping Record ti1�G2r `i_o2
Form 4
PEP has provided this form for use by local Boards of Health. Other fo used, but the
information must be substantially the same as that provided hare. 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: �ront
back side rear ?effttlright
right
A. FacilityInformation BUILDING: back side rear
Important:when DECK: under
filling out forms 1. System Location.
on the computer, f 10��
use only the lab }-
key to move your Add ess Ga
cursor-do not a MA use the return Cil (Town
key. y Stale Zip Code
2. System Owner:
Q t CO�e—
Name
rrun
Address (if different from location)
MA
Clly/Town Slate
Zip Code
9 1-S. 8 Z z&3
Telephone Number
B. Pumping Record
1. Date of Pumping p 9 D e�� 2 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 condili n of component pumped:
Porl`^�i
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1A 1Z
Name Vehicle License N ber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
� �1201�y
Signature of Hauler Dale
Signature of Receiving Facility(or,atlach facility receipt) Date
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