HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 CARLTON LANE 4/3/2023 Commonwealth of Massachusetts aECEtvED
City/Town of
System Pumping Record
Form 4 pVEH
TOWN OFH DEPANTMENY
DEP has provided this form for use by local Boards of Health. 0*1109rms 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. —....-
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, (51 I l n
use only the tab
key to move your Address - -
cursor-do not �(,�
use the return Ai dot, , ____ �4 o*gail
key. City/Town State
Zip Code
2. System Owner:
re6 l —.!._.1 C—
Name - --
rcru�n r
Address(if different from location) ----
City/Town . State
Zip Code
Telephone Number
B. Pumping Record
1. Date of 9 Pum In Lg
��
p Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 4 No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Iva�M
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name
Bateson Enterprises Inc Vehicle License N umber
Company
7, LQlion where contents were disposed:
GLS
Sign re auler A/_0_L/__—
Date — - --
Signature of Receiving Facility(or attach facility receipt) Date -
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