HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 CHRISTIAN WAY 11/27/2023 Commonwealth of Massachusetts
City/Town of "+
W° System Pumping Record �p
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 C M R 15.351.
A. Facility Information
Left/Right front of house, Left Right ear of house, Left/Right side of house, Under C
Important:when Left/Right side of building Left/ ig t front of building, Left/Right rear of building,
filling out forms 1. System Location: g g�
on the computer,
use only the tab o 1S —
key to move your Address S
cursor-do not MA �Q—l5
use the return Aclyown State Zip Code
key.
2. System Owner:
rib � �
�'
Name
Address(if different from location)
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date kho 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:
QC'r'A-A( - ---- - --- -------
6. System Pumped By: IAA 59
Dave Tiney Mas F58214 9
Name Vehicl Licens umber
Bateson Enterprises, Inc.
Company
7. o tion where contents were disposed:
GLSD
I I i�1z�
Signaturd of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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