HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 107 OLYMPIC LANE 3/27/2024 Commonwealth of Massachusetts
u City/Town of
F System Pumping Record
a
-Form 4 er-
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 rea 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, t�,yMA I use only the tab \0-T4 Ln
key to move your Address
cursor-do not �( I � MA
use the return City/Town
key. Slate Zip Code
,.e
2. System Owner:
11 r `
9�4 d 4J l.sL L
Name
Horn
Address(if different from location) .
MA
Cilyrrown State Zip Code
4nc-- c2
n �2- Z�St
Telephoe Number
B. Pumping Record
1. Date of Pumping 1 t4 Z 2. Quantity Pumped:
Date 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? ElYes [INo
5. Observed condition of component pumped:
�/SCMc`
6. System Pumped By:
Dave Tiney Mass F5821 AA EName Vehicle License Nu4EMass
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed.
GLS
Signature�uler Date3�
Signature of Receiving Facility(or attach facility receipt) Date
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