HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 OLD CART WAY 10/7/2022 Commonwealth of Massachusetts
City/Town of
System P RECEIVED
umping Record
Form 4
OCT 0 7 2022
DEP has provided this form for use by local Boards of Health. the
information must be substantially the same as that provided here.I FY P9iRdWMEFWn,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: front back 0 rear of right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:17 1 � .r y
on the computer, L1 f�
use only the tab
key to move your Address
cursor- not
use the return
urn /y
key. City/Town
State Zip Code
,an 2 Syste Owner: �
El 0
Name
rerom
Address(if different from location)
City/Town _
State
Zip Code
-7 - l
Telephone Number
B. Pumping Record o�
1. Date of Pumping SD
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank
❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes jxNo
�— If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave N Tiney
ame — — — Mass 1AA95E
Bateson Enterprises Inc Vehicle License Number
Company
7. Location where contents were disposed.
GLS
Signature of Hauler ------ —
Date
Signature of Receiving Facility(or attach facility receipt) Date
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