HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 PADDOCK LANE 11/21/2023 Commonwealth of Massachusetts �"'"' �
City/Town of
System Pumping Record
Form 4
�M
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.
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A. Facility Information BUILDING: nt back side rear left rig t
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Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date t 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:
- porgy
6. System Pumped By:
Dave Tiney MalF582 Mass 1AA95E
Name Vehi a Number
Bateson Enterprises, Inc.
Company
7. Lo tion where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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