HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 222 BRIDGES LANE 10/30/2023 L'\\ Commonwealth of Massachusetts
City/Town of -� p
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 ack side rear left Qgh
A. Facility Information BUILDING: front back side rear left
DECK: under
Important;When
filling out forms 1. System Location:
on the computer,use only-the tab `
key to move your Address
cursor-do not /(`�`J`1 - MA _
use the return cifyf ---- Stale Zip Code
key.
2. System Ownr:
fn
Name
Address (if d erenl from location)
_ MA
Cily/Town Slalc�.�� �p�de
Telephone Number 11((
B, Pumping Record
1. Date of Pumping 2. Quantity Pumped:
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 pumped:
I
6. System Pumped By:
Dave Tines _ Ma s F5821 Mass 1AA95E
Name Veh le License mbef
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD U
i Signal a auler Date
Signature of Receiving Facility(or attach facility receipt) Date
i
i
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