HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 36 HAWKINS LANE 10/2/2023 Commonwealth of Massachusetts e' `
City/Town of
a System Pumping Record
Form 4
QC
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: 5roDnt
back side rear left right
A. Facility Information BUILDING: back side rear left ri
Important:When DECK: under
filling out forms 1. System Location.
on the computer,use only the tab n��
key to move your Address
cursor-do not jj _ MAC y�
use the return City/Town State Zip Code
key.
2. System Owner:
e n t eke,
Name
�etun
Address (if different from location)
MA
City(Town State Zip Code
Telephone umber
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank El 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 pu ped:
It''6rk1-11,
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicle '1�rrTe Number
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
(!Lpion
SD
-- - -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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