HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 185 BRIDGES LANE 12/21/2023 Commonwealth of Massachusetts
= City/Town of
System Pumping Record 9
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 back ide rear left ri hot
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms' 1. System Location:
on the computer, c_
use only the tab c;T� a CJ -14
key to move your Address tj
cursor-do not t MA
use the return
key. City/Town �d-- State Zip Code
2. System Owner:
9G C4
Name
nnm
Address(if different from location).
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I r/ 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 f component pumped:
Aj0r�c
1 If
6. System Pumped By.-
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Num er
Bateson Enterprises, Inc.
Company
7. Loca ion where contents were disposed:
GLS
/Z f lIz
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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