HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 218 LACY STREET 9/1/2023 Commonwealth of Massachusetts
N City/Town of v,�. l�oti3
System Pumping Record
w '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.
_715-
HOUSE: front back side rear Gle right
A. Facility Information BUILDING: nt back side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer. y C`V
use only the tab Y �j—
key to move your Add e/ss ^ r
cursor-do not l � r' "� MA
use the return City/Town State Zip ode
key.
2. System Owner:
r� � M
Nam l 'nrDlt
ILA
Address(if different from location)
MA
City/Town State Zip Code
(�' n
Telephone Number
B. Pumping Record
1 Date of Pumping Date� 2� 2. Quantity Pumped: ll Gallonsns
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): L
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? / Yes ❑ No
5. Observed co di lion of component pumped:
6. System Pumped By:
Dave Tiney Mas F582 Mass 1AA95E
Name VehicleN64ao.%4 Number
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
6113
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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