HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 196 CARLTON LANE 10/24/2023 t �\
Commonwealth of Massachusetts
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 )ide 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, Mr- C`-A � ri
use only the tab
key to move your Ad ress istN
cursor-do not _ _ MA _ Ilk—1
use the return Cily(Town State Zip Code
key.
2. System Owner:
1�
Name
Address (if different from location)
VIA
City/Town State .Zip Code
Telephone Nur
B. Pumping Record
1. Date of Pumping Date ---- 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 condition of component p roped:
6. System Pumped By:
Dave Tin_ey _ Mass 582 Mass 1AA95E
Name Vehiclekicenso Number
Bateson Enterprises, Inc. _
Company
7. tion where contents were disposed:
GLSD
S �?r
ignature 67 Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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