HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 OLD CART WAY 10/24/2023 Commonwealth of Massachusetts <�o��?`' do
City/Town of �.:,�,�,� - %%
System Pumping Record
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. —'- -
HOUSE: fron back side rear eft right
A. Facility Information BUILDING: rout back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ILr
use only the lab ` 15- 0
key to move your Address
cursor-do not ��` _ MA _
use the return Cily/Town Stale Zip Code
key.
2. System Owner:
,d G
Name
Address (if different from location)
_ MA _ _ _
City/Town State Zip Code
Telephone Number
B. Pumping Record
/ 3
1. Date of Pumping [ jv ------- 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 conditi of component umped.
6. System Pumped By.
Dave Tiney _ Ma s F5821 Mass 1AA95E
Name Vehi Lic umber
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD
Signatu a of aufer Date
Signature of Receiving Facility(or attach facility receipt) Dale
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