HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 5/13/2024 N Commonwealth of Massachusetts
City/Town of 3 tioti�
System Pumping Record MP
Form 4 Fti
�M
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 si re le right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. S stem Location:
on the computer, ? yy� 8�01- ,
V
use only the tab ,J(_J � � d' �' '
key to move your Address
cursor-do not MA �
use the return
key. Citylrown State Zip Code
2. Sy wne
rab
- , 4 A
Name
arum
Address(if different from location)
MA
City/Town State i Code
3 3L
Telephone Number
B. Pumping Record f� C
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - —
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned?,'
leaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney — s 1 AA95E ass 1 AD31 Z
Name umber
Bateson Enterprises, Inc.
Company
7. Lo ion ere contents were disposed:
eLSD
S�-
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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