HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 184 CARLTON LANE 10/24/2023 Commonwealth of Massachusetts � '`J
City/Town of
a System Pumping Record
Form 4 OL
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: iron back ide re4eright
right
A. Facility Information BUILDING: front side rea
DECK: under
Important:When
filling out forms 1. System LOC�IOn:
on the computer, C,�� n
use only the lab
key to move your A dress
cursor-do not l4 MA
use the return City/Town State Zip Code
----
key.
2. System Owne
K42A - - -
Name
Address (if different from location)
MA ___ _
City/-rown State .Zip Code
-.- CW sue- $2G-
Telephone Number
B. Pumping Record � -�
1. Date of Pumping — ----- 2. Quantity Pumped: �ns
p g Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --- --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
i n of com onent m ed:
5. Observed con t o p P P
6. System Pumped By:
Dave Tines_ _ Mas F5821 Mass 1AA95E
Name Vehicle en umber
Bateson Enterprises, Inc.
Company
7. oc on where contents were disposed:
G _SD
I
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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