HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 WINTERGREEN DRIVE 12/21/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record 11p13
a �
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.
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HOUSE: front ack ide rear le right
A. Facility Information BUILDING: front side rear right
Important:When DECK: under
filling out forms 1. System Location.
on the he tabcomputer, -� n
use only the tab w
key to move your Address
cursor not return
,,
use the return '�`mow MA
key. Cityrrown State
Zip Code
Q2. System Owner:
WE Name
11
RAO 4.
Address(if different from location) .
MA
CityrTown State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping o��It��� 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:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nu er
Bateson Enterprises Inc.
Company
7. tion where contents were disposed:
LSD
12/, z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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