HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 SUGARCANE LANE 5/8/2023 Commonwealth of Massachusetts AECEo
City/Town of
System Pumping Record
Form 4 OWNOF�NI�E
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
local Board of Health to determine the form they use. The System Pumping .Record must be submitte
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - - -
HOUSE: <:asback side rear left
A, Facility Information BUILDING: front ba.ck side rear left rig
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, /• ;
use only the tab �p ,
key to move your Address
cursor-do not � � � �r►.�sl Q �
use the return Cily/Town State_ Zip Code
key.
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2. System Own r:
i owl eas1�
Name
niwn
Address (if different from location)
City/Town . State Zip Code
5G 1-3361
Telephone Number
B. Pumping Record
� 2 �-�-,
1. Date of Pumping D 2. Quantity Pumped: Gallons
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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 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. tion where contents were disposed.-
LSD
Ii S
Signature ofRauler Date T ��
Signature of Receiving Facility(or attach facility receipt) Dale
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