HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 1/23/2024 _\ Commonwealth of Massachusetts CON
City/Town of LPN ti31���
System Pumping Record
Form 4 � Q
DEP has provided this form for use by local Boards of Health. Other for 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.
A. Facility Information_______-_
Left fight�o n t of house, Left/ Right rear of house, Left/Right side of house, Under Dec
Important:When
filling out forms 1. System Location: Left/Rig t side of building, Left/Right front of building, Left/Right rear of building,
on the computer, 12 GAriCd
use only the tab
key to move your Address
cursor-do not [ram / MA
use the return City/Town jjj State Zip Code
key.
2. tem Owner:
tab
TA,4
Name
re2m
Address(if different from location)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record Id
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) P4eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): — - — —
4. Effluent Tee Filter present? ❑ Yes�No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi�,ofjomponent pumped:
6. System Pumped By:
Dave Tiney _ __ _ Mass F5821 IMA 1A4 9
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
ZL7. Lotf6n Where contents were disposed:D -
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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