HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 143 DUNCAN DRIVE 10/30/2023 Commonwealth of Massachusetts
H City/Town of
System Pumping umping Record ��34
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. _
ck side rear le right
A. Facility Information HOUSE: front ba
BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return t 'e— MA
key. City/Town — — --
State Zip Code
2. System Owner:
�i ►��r-�.Cs�n
Name
anvn
Address(if different from location)
City/Town MA
State
Zip Code
q, '*-
Telephone Number
B. Pumping Record
1. Date of Pumping Dat/ 2 2. Quantity Pumped: `5
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ 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 -Finey Mas F5821 Mass 1AA95E
Name Vehic Licen umber
Bateson Enterprises, Inc.
Company --—
7. on where contents were disposed:
LSD
Signature of Hauler Date —
Signature of Receiving Facility(or attach facility receipt) Date
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