HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 STONECLEAVE ROAD 10/24/2023 Commonwealth of Massachusetts
City/Town of
a 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.
A. Facility Information
Left/Right front of house, Left Right ar-of house, Left/Right side of house, Under Dec
Important:When
filling out forms 1. st� L�a ion: Left—//Right side ofbuilding, Left/ Right front of building, Left/Right rear of building,
on the computer, ' J �tGhL0.
use only the tab IUUfCCL��D�- .��a Vim/ - - --
key to move your Address
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cursor-do not � T �— ( %u'�-vim- MA ` 3
use the return
key. City/Town State Zip Code
2. S stem Owner:
reb
Name
remm
Address(if different from location)
MA
City/Town State/� Zip Code
Telephone NumbG/er
B. Pumping Record /
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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 F5821 A IA4 9 Q
Name Vehicle Lice umber
Bateson Enterprises, Inc.
Company
7. Loca ' ere contents were disposed:
l
LSD
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Signature of Hauler ate
Signature of Receiving Facility(or attach facility receipt) Date
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