HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 CARLTON LANE 4/17/2024 Commonwealth of Massadhus-etts °,
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 aulhority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear left rig
A. Facility Information BUILDING: nt back side rear leh right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab - G:1 Ce"r-
key to move your Addre
use the return K�ss
cursor•do not �A^ MA
— ---- --- ---
key. City/Town Stale Zip Code
r�
2. Syste Owner:
Name
nMn
Address (if different from location) .
MA
Cily/Town Stale
Zip Code
��2-606. 2y'6 Z
Telephone Number
B. Pumping Record `/
1. Dale of Pumping Date(ll 2 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? I—) YesNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition.of component ped:
lUb rn^C
6. System Pumped By:
Dave Tiney Mass F5821 ass 1AA95
Name vehicle license mber
Bateson Enlerprises, Inc.
Company
7. oc on where contents were disposed:
GLSD
Signal ure o Hauler Dale -
signature of Receiving Facility(or attach facility(eceipl) Dale
15form4.doc• 11/12
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