HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 MILL ROAD 9/1/2023 Commonwealth of Massachusetts
N City/Town of
System Pumping Record �1
Q
Form 4
G M
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: front back ide WE left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, C'Ld �� Z
use only the tab --
key to move your Address C
cursor-do not ,Q/ MA Q 6� y(
use the return - ' y - --- --- - -- -- -
key.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date` L1 L 2. Quantity Pumped: 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.
-moo r M��--- ---_-- -- - - -- --
6. System Pumped By:
Dave Tiney Ma s F5821 Mass 1AA95E
Name Vehi le License umber
Bateson Enterprises, Inc.
Company
7. 'on where contents were disposed:
GLSD
Signatur of auler Date
- --- - --- -- - — - -- - -
Signature of Receiving Facility(or attach facility receipt) Date
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