HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 249 CARLTON LANE 5/6/2024 � Commonwealth of Massachusetts
City/Town of MAYG 2�24
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 dale in
accordance with 310 CMR 15.351.
HOUSE: front bac side rea left right
A. Facility Information BUILDING: front back side rear leh right
Important:When DECK: under
filling oul forms 1. System Location:
on the computer,
use only the lab
key to move your Address
- MA
cursor•do not N
use the return �/V
key. Cilyrrown Stale Zip Code
2. Sy termV�,x—
NameOwner:
rd r
nnrn \
Address (it different from location).
MA
Ci(y/Town Stale
Zip Code
Telephone Number
B, Pumping Record
1. Dale of Pumping '�o 12`�
p g 1
Dale 2. Quantity Pumped Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Etfluenl Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component pumped:
6. System Pumped By: iZ I AD7—
Dave Tiney Mass Ft-s�l Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7, lion where contents were disposed:
GLS
Signature of Hauler Dale
Signature of Receiving Facility(or altach facility(eceipt) Oale
15form4,doc- 11/12
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