HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 DUNCAN DRIVE 10/24/2023 IL
Commonwealth of Massachusetts
City/Town of
System Pumping Record 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 fide rear left fight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab irl-
key to move your Address n
cursor-do not N ,I 4-., MA 0 iS;4 S_
use the return City/Town State Zip Code
key.
2. System Owner:
lob WASon
Name
Address (if different from location)
MA _
City/Town State .Zip Code
Telephone Number
B. Pumping Record
I 1. Date of Pumping Date Gallons
2 Quantity Pumped: Ill ns
I 3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
1 ❑ -
Other (describe): —-
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed con ition of component pu ped:
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AA95E
Name Vehicl License umber
Bateson Enterprises, Inc. _
Company
7. (a,on where contents were disposed:
—
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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