HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 TURTLE LANE 11/21/2023 Commonwealth of Massachusetts
City/Town of
P
System Pumping Record v �A.10�
Form 4 �0
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 ack sde rear le right
A. Facility Information BUILDING: back side rear left ri
Important:When DECK: under
filling out forms 1. System Location.-
on the computer, f-17
use only the tab `�v �(,�r 4 Gn
key to move your r+a ess - --
cursor- not 1-'�l,e/ MA C�t
use the return
key. City/Town State Zip Code
2. System Owner:
.. cr.'rI SC -
Name
nnm
Address (if different from location) -- --
MA
City/Town State
GnL l/^Z�i/p`/Code
`
l 1 J r`4+'I G 5
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 p mped:
6. System Pumped By:
Dave Tiney MasoicNmber
Mass 1AA95E
Name Vehicl
Bateson Enterprises Inc.
Company
7. where contents were disposed:
eion
Signature of Hauler Date -- --—
Signature of Receiving Facility(or attach facility receipt) Date -
t5form4.doc•11/12 System Pumping Record -Page 1 of 1