HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 OLYMPIC LANE 11/27/2023 Commonwealth of Massachusetts
City/Town of o,
a
System Pumping Record V ��
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. -
HOUSE: front bac side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab w G'
key to move your Address
cursor-do not MA
use the return Cit /Town
key. y State Zip Code
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2. System Owner:
l Q
CC 1Soc'otb
Name
rerun
Address(if different from location)
MA
Cityrrown State Zip Code
4r 3yc,3
Telephone Number
B. Pumping Record
1. Date of Pumping 110IZ -- 2. Quantity Pumped: � ----
Date 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 F582 Mass 1AA95E
Name Vehi le Licen Number
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed.-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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