HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 249 CARLTON LANE 4/19/2022 BECEIVEO
Commonwealth of Massachusetts
City/Town of APR 19 2022
System Pumping Record WNOFNDR-fHANDUVER
HEAI.TH pEPARTMENT
Form 4 TO
�M
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 the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Left/Right front of house, Left/Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/Right front of building, Le Right-rear o building,
on the computer, at1q
use only the tab
key to move your �As _
cursor-do not _ _ MA G���5
use the return y/Town State Zip Code
key.
2. Sy m Owner:.
Na e
remm
Address(if different from location)
MA
City/Town State 6� � � Zip Code
' —
Telep one Number
B. Pumping Record
1. Date of Pumping — - "� — 2. Quantity Pumped:
ate Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): — -
4. Effluent Tee Filter present? ❑ Yelj�'No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition
/off component umped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson_Enterprises, Inc.
Company
7. 1-5 i n where contents were disposed:
(!G L S D
- - -
Signature of Hau r Date
Signature of Receiving Facility(or attach facility receipt) Date
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