HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 CARLTON LANE 10/24/2023 Commonwealth of Massachusetts
N City/Town of �tioti3
a System Pumping Record
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 ack side rear left righ
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, t
use only the tab 120
key to move your Address
cursor-do not 0 _ _ MA
use the return City(Town Stale Zip Code
key.
2. System Owner:
�on. !;e
�`
Name
Address (if different from location)
_ MA
Cilyrrown State Zip Code
Telephone Number
B. Pumping Record
AD— XZZ
1. Date of Pumping Date' ' T 2. Quantity Pumped: 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
5. Observed conditi f component pumped:
n o
6. System Pumped By:
Dave Tined M a s F5821 Mass 1AA95E
Name Vehicl Licens Number
Bateson Enterprises, Inc. _
Company
7. tion where contents were disposed:
GLS —_
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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