HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 192 STONECLEAVE ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of of
System Pumping Record ti3
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
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.
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HOUSE: fro r(
back side rea left ri
A. Facility Information BUILDING: front c side rear left ri,
DECK: under
Important:When
filling out forms 1. System LocDAena�,P,--
tin.
on the computer,
use only the lab ��I,
key to move your t
ress
cursor•do notuse the return
key. City/Town Slate Zip Code
2. Sy to Owner:
Name
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Address (if different from location)
Cily/Town . State Zip
^� /� G G']Zip Code
`l T� -co Og-' (-I::.
Telephone Number
B. Pumping Record
1. Date of Pamping 2'3 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tral
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. where contents were disposed:
GLS(M-efDon
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
t5(orm4.doc• 11112 System Pumping Record - PaRe