HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TUCKER FARM ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 �V
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. —
HOUSE: front back sid rear Orightl.
A. Facility Information BUILDING: front back side rear left right
DECK: under
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key. CK/fiown State Zip Code
2. S stem Owner:
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Name
raven '
Address (if different from location)
City/Town State 591> %G^6122-Zip Code
Telephone Number
B. Pumping Record -
1. Date of Pumping Date 2. Quantity Pumped: � a
1 Gallons
3. Component: El 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. Location where content were disposed:
GLSD
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
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