HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 213 CARLTON LANE 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
Important:When
U�/
Right front of house, Left/ Right rear of house, Left/ Right side of house, Under Dec
filling out forms 1. System Location Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer, -+Q C , I
use only the tab 47
key to move your Address
cursor-do not MA 61& I
use the return tZnCJQl - ------ -
key.
City/Town State Zip Code
� 2. System Owner: i +
be-(i s5n ------
Name
rerun
Address(if different from location)
_MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 3—-- 2. Quantity Pumped.
Date Gallons
3. Component: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — --- /---—
4. Effluent Tee Filter present? /[� Yes El No If yes, was it cleaned? 4 Yes ❑ No
5. Observed condition of component pumped:
_ � -
6. System Pumped By:
Dave Tine _ _ Ma F582
Name Vehicl nse/,m�b"e "+��
Bateson Enterprises, Inc.
Company ---- ------
7. L tion where contents were disposed:
G LS D ,(1�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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