HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 205 FOREST STREET 9/6/2024 Commonwealth of Massachusetts
t - V City/Town of
System Pumping Record f„
Form w
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 -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back sid rear e right
A. Facility Information BUILDING: front back side rear left right
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out forms 1. System Locati
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cursor-do not �AAb MA
use the return Cwn
key. y State Zip Code
2. System Ow er:
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Address(if different from location)
MA
City/Town State „Zip Code
Telephone Number l/•(j "��
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95 Mass 1AD31Z
Name Vehicle License ber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
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Signature of HauleV Date
Signature of Receiving Facility(or attach facility receipt) Date
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