HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 7/17/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 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.
A. Facility Information
Left/Right front of house, Left/ ight ear of house, Left/Right side of house, Under C
Important:When
filling out forms 1. System Location: Left/Right side of building, Left/Rig t front of building, Left/Right rear of building,
on the computer,
use only the tabK—
key to move your Address
cursor-do not N, �� R� MA 01
use the return City/Town State Zip Code
key.
2. System Owner:
lv\kk e Se (V.C,n I L,k
Name
etum
Address(if different from location)
MA
Cityrrown State Zip Code
9�� -`1"�f �y2��
Telephone Number
B. Pumping Record
1. Date of Pumping 2. QuantityPumped:p g Da e p Gallons
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 Iof component pumped
6. System Pumped By:
Dave Tiney Mas F582 1AA
Name Vehicle umber
Bateson Enterprises, Inc_
Company
7. ion where contents were disposed.
LSD
- - --- 1z�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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