HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 LACONIA CIRCLE 12/4/2023 Commonwealth of Massachusetts P�SJ`✓
City/Town of
a System Pumping Record 0�`�
Form 4
�1
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 side rear le 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 (�C'C-cn\s C <-
key to move your Ad re s
cursor-do notNV MA
use the return City/Town
key. State Zip Code
2. System Owner:
reb QC,k�
Name
stun
Address(if different from location) .
_ MA
City/Town State ip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date O Z 2. Quantity Pumped: -
Gallons
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank El Grease Trap
❑ Other (describe): -- - - — -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pulped.
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6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD q/
0�0 t/ c, L
Signature of Hauler Date
9 Signature of Receiving Facility(or attach facility receipt) Date
i
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