HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 COLONIAL AVENUE 10/30/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record ptt
w 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 bac ide rear left QrightA. Facility Information BUILDING: front back side rear left
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, 6�
use only the tab
Co`7 ``!z,1
key to move your Address
cursor-do not _ MA
use the return City/Town State Zip Code
key.
2. System Owner'
�s
Name
Address (if different from location)
MA
City/Town ---- — — State ------ Zip Code --
Telephone Number
B. Pumping Record
1. Date of Pumping �'r3 Zy — 2. Quantity Pumped: X
p g y /,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 condition of component pu ped:
& System Pumped By:
Dave Tined M&F5821Mass 1AA95E
Name Vember
Bateson Enterprises, Inc. _
Company
7. CGLS
ion where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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