HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 133 COLONIAL AVENUE 10/24/2023 Commonwealth of Massachusetts
1.0
City/Town of
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: front bac side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, of ,NUC_
use only the tab
key to move your Address
cursor-do not P - MA —CA S79Sr
use the return City/Town Slate Zip Code
key.
2. System Owner:
�r
rC �cClP�rs lik n
Name
Address(if different from location)
_ MA
City/-rown State .Zip Code
Telephone Number
B, Pumping Record
1. Date of Pumping Tc—' ---- 2. Quantity Pumped:
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
5. Observed 'condition of component pumped:
6. System Pumped By:
Dave Tiney _ __ Mas F582 Mass 1AA95E
Name VehiclllLicense umber
Bateson Enterprises, Inc. _
Company
7. on where contents were disposed
GLSD 11
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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