HomeMy WebLinkAboutSeptic Tank w/ filter - Septic Pumping Slip - 9 TURTLE LANE 9/21/2023 Commonwealth of Massachusetts
City/Town of �1`Loti3
System Pumping Record S�Q
w Form 4
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 baC side rear left right
A. Facility Information BUILDING: front back side rear left right
��u n
Important:When DECK: under f i7v�
filling out forms 1. System Location:
on the computer, (� /✓ t r ,- „
use only the tab l (Q [�[{J�l� _
key to move your Addres p 1
cursor- not t' A4� ` � MA �o S
use the return key. City/Town State Zip Cod
2. Syst Ownetab D
�
Name
relun
Address(if different from location)
MA
City/Town S1W-17cl
to Zip Code
�g/o
Tel phone Number
B. Pumping Record
q� V,
1. Date of Pumping -Da e 2. Quantity Pumped. Gallons
3. Component: ❑ Cesspool(s) dSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): V 1 4ey - — - -- -
4. Effluent Tee Filter present? [ Yes ❑ No If yes, was it cleaned? tfYes ❑ No
5. Observed condition of component pumped.
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95E
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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