HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 CARLTON LANE 4/17/2024 Commonwealth of Massachusetts
City/Town of APR 17 2024
System Pumping Record
Form 4 _,;°; -,tme11t
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 ack 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,
use only the lab C
key to move your AddressAi
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cursor- not vv Q `iS
use the return
urn h(J, MA
key. CilyfTown State Zip Code
ua
2. System Own
Cq
Name
nnm
Address (if different from location) .
MA
CilyrTown Slate Zip Code
7-8- 1{ppg- o{3 S_
Telephone Number
B, Pumping Record
1. Date of Pumping Dale 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of cols o ent pumped:
Sy66
6. System Pumped By:
Dave Tiney Mass F5821 !ass 1AA
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. (5—c-*** n where contents were disposed:
U
Signature of aulef Date Z
Signature of Receiving Facilily(or attach facility receipt) Date
15form4.doc- 11/12
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