HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 9 TURTLE LANE 4/19/2022 Commonwealth of Massachusetts 191011
City/Town of p,QR P�ADO
System Pumping Record owNOfNoti P�MaN�
Form 4
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, Left/Right rear of building,
on the computer, /� i _' /�qh/�_
use only the tab I��VV _ _
key to move your AW o� _ _
cursor-do not MA
use the return City/Town State Zip Code
key.
2. System Owner:
Name
Isom
Address(if different from location)
MA
City/Town State � Zip Code
Telephone Number
B. Pumping Record �/_ d?
1. Date of Pumping - 2. Quantity Pumped:
Date 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 F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
ZX4)-
--- -- —
Signature oYH r Date
Signature of Receiving Facility(or attach facility receipt) Date
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