HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 22 RALEIGH TAVERN LANE 10/24/2023 Commonwealth of Massachusetts
City/Town of
x a System Pumping Record `�✓r pC�
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: front back side rearQleright
A. Facility Information BUILDING: t back side rearight
DECK: under
Important:When
filling out forms 1. System Loc tion:
on the computer, �� t�—�
use only the tab __
key to move your Ad ress CC
cursor-do not MA
use the return — —
City/Town Stale Zip Code
key.
2. System Owner:
Name
Address (if ditferent from location)
_ MA _ _ _
Zi Co
City/-rown Slate de
Telephone Number
B. Pumping Record
lU/li12 3 1. Date of Pumping Date T—---- 2. Quantity Pumped: rIS06
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 _ Mas F5821 Mass 1AA95E
Name Vehic License umber
Bateson Enterprises, Inc.
Company
7. Con where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
i
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