HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 BRIDGES LANE 10/30/2023 Commonwealth of Massachusetts
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City/Town of .���` ti®"-�
b System Pumping Record
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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. - g
HOUSE: front ac ide rea le ri ht
A. Facility Information BUILDING: front bac side rear a right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the lab IC46 - (41n�
key to move your A ress
cursor-do not �- MA _ —0 11_
use the return tyfTown ---- State Zip Code
key.
2. System Oyvner ` - -
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Name
Address (if different from location)
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City/Town State — � .Zip Code
Telephone Number
B. Pumping Record .,, I�,��, ���-
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1. Date of Pumping Date 2. Quantity Pumped: 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 p mped:
6. System Pumped By:
Dave Tiney _ Mass 5821 Mass 1AA95E
Name Vehicle ense N ber
Bateson Enterprises, Inc. _
Company
7. ion where contents were disposed:
GLSD
Q
Signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4,doa 11112 System Pumping Record Page 1 of 1
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