HomeMy WebLinkAbout- Septic Pumping Slip - 78 LACY STREET 10/24/2023 �L\ Commonwealth of Massachusetts
City/Town of 0101
System Pumping Record qC��
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.
A. Facility Info tion
Le Right front of house, Left/Right rear-of house, Left/Right side of house, Under t
Important:when eft/Right side of building, Left/Right front of building, Left/Right rear of building,
filling out forms 1. System location:
on the computer, li/
use only the tab ---- --- -
key to move your Ad ess
cursor-do not _ MA ��
use the return City/Town State Zip Code
key.
2. Sy tem Owner:
Name
faun _--
Address(if different from location)
MA
City/Town State Zip Code
Telephone Wumber
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 pumped:
6. System Pumped By:
Dave Tiney Mass F5 �44
Name Vehicle Lic um
Bateson Enterprises, Inc.
Company
7. Location where conte were disposed:
GLSD
Sirnaklfle of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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