HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 WHITE BIRCH LANE 10/24/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record %K�
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 ide rear left righ
A. Facility Information BUILDING: front ack side rear left rig
DECK: under
Important:When
filling out forms 1. System Loc tion: f
on the computer, W�
use only the tab `/(7 CUI`
key to move your Ad re s A t (+
cursor-do not \-�1t��0�`�,p`�' _ MA
use the return key. City/Town State Zip Code
2. Syste O ner:
Yl ct V' 4-e-42r, ��A-e
Name -
Hahn
Address(if different from location)
MA
City/'Town State Zip Code
9qCis-,� 61SZ
Telephone Number
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 c mponent p mped:
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95E
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
Ga
LSD
-- -
AU 12-IL)--
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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