HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 189 CARLTON LANE 5/10/2022 IECEI\JF
Commonwealth of Massachusetts
City/Town of Mpy 10 2022
- System Pumping Record OF N T
'NOR-TVA ANDU
Form 4 OHvER
N -TH OEPARTMEN
ha,
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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted t(
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information HOUSE: rout ask side rea(
Important:When BUILDING: front back side rear left
filling out forms 1. Sb stem Location:
on the computer, I CA
/ t AK A DECK: under
use only the tab l� � --
key to move your Address /n�
cursor-do not �G n�l ��� i�''�
use the return City/Town State Zip Code
key.
2. Sy to Owner:
n&tt) -
Name
mrun
Address(if different from location)
City/Town State �j Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ----- -
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney _ _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc xthere contents were disposed:
LSD
— - ----JV
-
Signature of Hauler Date