HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 210 CANDLESTICK ROAD 9/21/2023 Commonwealth of Massachusetts
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City/Town of
System Pumping Record V\
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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: front ck side rear left i ht
A. Facility Information BUILDING: front back side rear left right
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B. Pumping Record
1 Date of Pumping Date - 2. Quantity Pumped: Gallons
3 Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nurlllzr
Bateson Enterprises, Inc.
Company
7. Locatio where contents were disposed:
LS
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt) Date
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