HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 CARLTON LANE 10/24/2023 i
n� Commonwealth of Massachusetts
City/Town of
a 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: front ac side rear left right
A. Facility Information BUILDING: front ack side rear left right
DECK: under
Important:When
filling out forms 1. System Loca Cion:Z
on the computer, � Cuse only the labJ f �
key to move your Address ^ cc
cursor•do not C6�� _ MA _ —11_ta S
use the return ily/Town Stale Zip Code
key.
2. System Owner: 2 1
Name
Address (if different from location)
_ MA
Cily/Town State .Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping --'_' ---- 2. Quantity Pumped. —r�
Dale 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 condition f component pumped
—tom
6. System Pumped By.
Dave Tines _ Ma rsF5821 Mass 1AA95E
Name Veht le License mber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
Signature of Hauler Oale
Signature of Receiving Facility(-or attach facility receipt) Date
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