HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TURTLE LANE 11/27/2023 CS r.��.��1•
Commonwealth of Massachusetts
City/Town of
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.
A. Facility Information
Left/Right front of house, Left/Right rear-of house, Left/ igh ide of house, Under C
Important:when g
Left/Right side of building, Left/Right front of building, /Right rear of building,
filling out forms 1. System Location: g � Le g g g
on the computer, !!��
use only the tab J6- 1L<e //1
key to move your Ad ress
cursor-do not ,/,4C11til, 8� MA
use the return City/Town State Zip Code
key.
2. System Owner:
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Name
ream '
Address(if different from location)
MA
City/Town State Zip Code
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 of component pumped
6. System Pumped By:
Dave Tiney - - _ Ma F5821 1AA A4 9/9 Z
Name Vehi License umber
Bateson Enterprises, Inc.
Company
7. c 'on where contents were disposed:
GLSD
Signature o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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