HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 VEST WAY 7/3/2023 Commonwealth of Massachusetts
City/Town of
a �
System Pumping Record
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{ Form 4 Y
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 Syste.m 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: CDback side rear left ,
A. Facility Information BUILDING: front ba.ck side rear left ril
DECK: under
Important:When
filling out forms 1. System Locations on the computer,
use only the lab is t� UP A W
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
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�M�l��q�e, r
Name
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Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D� 1`3 2. Quantity Pumped: Gallons
3, Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Traf
❑ 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. Loza ion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or atlach facility receipt) Date
15form4.doc- 11/12 System Pumping Record - Page