HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 RALEIGH TAVERN LANE 1/2/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record �pN
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 side rear eft right
A. Facility Information BUILDING: front back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
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on the computer, Ie t V�
use onlythe tab (.f��
key to move your Address)
cursor- not t\ ��� ^' ( k qC
use the return
urn /'�+` MA V
key. City/Town State
Zip Code
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2. System Owner:
enne
Name
rerun
Address(if different from location) .
MA
Cityrrown State Zip Code
Co 11, 9a U-Gag-?
Telephone Number
B. Pumping Record
1. Date of Pumping -1-k6
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ylY es ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
t'M 4
( - ----
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name
Vehicle License tuber
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
GLSD
IZ `15 3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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