HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 224 CARLTON LANE 4/29/2024 Commonwealth of Massachusetts
q1 (� City/Town of R 2 9 2�24
�iiS e�rx�. .r iaii�ri m�ca:e� � Ap
%ay L too a &ai VesRZa e ♦vwv
Form 4
DEP has provided this form for use by local Boards of Health. Oforms 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.
A. Facility Information _ — —�__ . .....
Left/ Right front of house Left/ ght rear-of house, Left/Right side of house, Under C
Important:When
filling out forms 1. S�� tem Location: Left/ R'gh�t side of building, left/Right front of building, Left/Right rear of building,
on the computer, -
use only the tab
—---------
key to move your Add res
cursor-do not MA
use the return - C-- -F -- -'--
key. Cityrrown State Zip Code
2 Sys m Owner:
Name
Address(if different from location)
MA _
�ity/Town St al - 7' Code
V_ / 3
Telephone Number
B. Pumping Rp-cord
1 hate of Pumping pate - 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(S) �'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —-- - -- --- —
4. Effluent Tee Filter present? ❑ Yo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
I
I 6. System Pumped By:
I Dave Tine_ - — Mass F5821 / 14 1 y4
p(
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. L on w e contents were disposed:
' G
Sign C/
ature of H r Date
SiUnatme of r owpiving F;4eility(or attach facility roceipl', n;aic-- - -
t5form4.doc• 11/12 System Pumping Record •Page 1 of 1