HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 TANGLEWOOD LANE 10/24/2023 Commonwealth of Massachusetts
w City/Town of 0101
System Pumping Record
Form 4
M
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: fron bac 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, /p�``rr-'
use only the tab 1v I CVN 1 t-'z0
key to move your Ades
cursor-do not GU� MA Q S
use the return City/Town State Zip Code
key.
2. System Owner:
Name
stun
Address (if different from location)
MA
City/Town Sta Zip Code
�g a-sz�2-
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z 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 F5821 �1�95
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS -r
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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