HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 123 MARIAN DRIVE 10/30/2023 Commonwealth of Massachusetts
City/Town of
aX System Pumping Record oti
Form 4 oCt
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: fron back I�Ie
A. Facility Information BUILDING: front ack si
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Actress — —
cursor-do not
use the return MA �(� ld
key. City/Town State
Zip Code
VQ 2. System Owner:
C1lCtCOd�
Name - — - --- —--
rerun
Address(if different from location)
City/Town -_ --_ MA
State
de
Telephone Number -
B. Pumping Record
1. Date of Pumping Sk
Date 2 2. Quantity Pumped: f�Z
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes El If yes, was it cleaned? (-11 Yes ❑ No
5. Observed condition of co ponent pumped: r
"" tq5'
6. System Pumped By:
Dave Tiney __ ______ Mas F5821 Mass 1AA95E
Name Vehicl License tuber
Bateson Enterprises, Inc.
Company _ -- —
7. o ion where contents were disposed.
GLSD
—
Signature of Hauler 7
Date
Signature of Receiving Facility(or attach facility receipt) Date --
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