HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 CANDLESTICK ROAD 8/23/2023 Commonwealth of Massachusetts
= City/Town of F�INo�F tioti3
a 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.
HOUSE: fron back ide rear left right
A. Facility Information BUILDING: front ac side rear left ri
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, �J Q ae sV A
use only the tab `�✓ ��jj" ----
key to move your Address
cursor-do not MA _
use the return _- Q��4S
Ci y/Town State Zip Code
key.
2. System Owner:
Name
ream _ -- -- -
Address(if different from location)
MA
City/rown State Zip Code
CL 1 -333- '-IGCI
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped. kzo
Date 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 of component pumped:
6. System Pumped By:
Dave Tiney Mas F5821; �ass 1AA95E
Name Vehicl License
Bateson Enterprises, Inc.
Company
7. oc n where contents were disposed:
GLSD
2,za - -
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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