HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 29 NORTH CROSS ROAD 3/29/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 left �ht
A. Facility Information BUILDING: front ack side rear left rig
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, AA . ` \ �
use only the lab G` wOt',{' }
key to move your Addrevss�
cursor•do not � } j6Vq- MA
use the return 1
key. City/Town Slate Zip Code
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2. System Owner:
Name
r
nMn
Address (if different from location).
MA
Cilyrrown Slate Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed cc�ondi on of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD
IZ,4
Signature of Hauler Dale
Signature of Receiving Facility(or atlach facility receipt) Dale
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