HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 161 BRIDGES LANE 10/30/2023 F\
Commonwealth of Massachusetts
City/Town of ®C�
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.
HOUSE: front ac side rear(in right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, p/ p n
use only the tab A0_ -
keyto move your Ad�dr e
cur / �� -- — MA O ��
cursor•do not //�"�-j _
use the return Cityrrown Stale Zip Code
key.
2. System Owner: —
d J`
� Name C — _ --
Address (if dMerenl from location)
_ MA
Cily/Town State .Zip Code
Telephone Number
B. Pumping Record <V
— 2. Quantity Pumped: Gallons
1. Date of Pumping Dale
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 Tines _ Mass 5821 Mass 1AA95E
s Name Vehicle icens umber
Bateson Enterprises, Inc.
Company
7. noiczon where contents were disposed:G
t Q�
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receip() Dale
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