HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 189 CARLTON LANE 7/3/2023 Commonwealth of Massachusetts
Cl'ty/Town of
u. 2
System Pumping Record
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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: front back side rear left Cl.
A. Facility Information BUILDING: front ba.ck side rear left ril
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, tc� c�1� 1
use only the tab
key to move your Address
cursor.do not n
use the return key. City/Town State Zip Code
2. System Owner:
r
Name
rrran
Address (if different from location)
Clty/Town . State Zip Code
Ree F -C&q
Telephone Number
B. Pumping Record
1. Date of Pumping oal� 2 2. Quantity Pumped: Gallonsr
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trar
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed
conndition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Nation where contents were disposed.
Signature of au er Date
Signature of Receiving Facility(or attach facility receipt) Date
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