HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 CEDAR LANE 3/15/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record MPS
Form 4
DEP has provided this form for use by local Boards of Health. Other for y be used, but the
information must be substantially the same as that provided here. Beformsing 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. 11
HOUSE: front ac side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, i
use only the lab Z5- Ce
key to move your Address
cursor•do not &t1pl — MA
use the return Cil /Town
key. y Stale Zip Code
rd 2. System Owner:
(�
Uinn�e tSCd.nrZ
Name
nnm
Address (if different from location) .
MA
Cityrrown State Zip Code
Telephone Number
B, Pumping Record
1. Date of Pumping oe�t�fLY 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes J 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 Licens Number
Bateson Enterprises, Inc.
Company
7, ation where contents were disposed:
GLSD
I 2
_§ignaturt of Hauler Dale
Signature of Receiving Facility(or attach facility(eceipt) Date
l5form4.doc-11/12
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