HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 333 CANDLESTICK ROAD 3/29/2024 rA
Commonwealth of Massachusetts
City/Town of � v° g TO
a
System Pumping Record MP�� erti
Form 4 e,Q2#0
DEP has provided this form for use by local Boards of Health. Other forms matjpeAd, 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 bac side rear eft right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, qqq C Ji f �� ?A
use only the lab --?�> M �3
key to move your Address
cursor•do not 1p Woulp, MA
use the return
key. Cily/Town Slate Zip Code
2. System Owner:
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Name (�
nnm
Address (if different from location).
MA
City/Town State Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping date — 2. Quantity Pumped: Gallon
3. Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component pumped:
6. System Pumped By.-
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
Signature of Hauler Dale
Signature of Receiving Facility(of attach facility receipt) Date
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