HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 VEST WAY 10/30/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record p'
Form 4
M
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 side ear eft ight
A. Facility Information BUILDING: front back sl a rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, r [ r eSV
use only the tab `{ l/
key to move your Address i
cursor-do not �Cc � MA
use the return key. City/Town State Zip Code
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2. System Owner:
e. W g'—k
ame
rerun
Address(if different from location)
MA
City/Town State Zip Code
sc/- got-�ar�
Telephone Number
B. Pumping Record
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 f component pumped:
P6 c �
6. System Pumped By:
Dave Tiney Mas F5821\ Mass 1A_A95E
Name Vehic License umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
01� 2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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