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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 CRICKET LANE 9/21/2023 r � Commonwealth of Massachusetts w City/Town of System P Form 4 Pumping Record \,,. t(Q �1 4fM SV 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 BUILDING: rout— HOUSE: back side rear left right front back side rear left right Important:When DECK: under filling out forms 1. System Location: the computer, use only tab 1�re ul, key to move your Address cursor- not W. A AAo' v use the return , V urn MA key. Cityrrown State Zip Code 2. System Own I 1, N e - - -- i Address(if different from location) CityrTown MA State Zip Code CAI -- S0101 - soaQ Telephone Number B. Pumping Record 1 Date of Pumping I 1 1a3 IS ©� Date 2. Quantity Pumped: Gallons 3. Component: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank 9 ❑ 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 Name Vehicle Ma F5821 Ma_s_s_1AA95E - -- Bateson Enterprises Inc. icle umber Company 7. Location where contents were disposed: GLSD ---------------- bignatuYe of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc- 11/12 System Pumping Record•Page 1 of 1