HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 OGUNQUIT ROAD 5/13/2024 Commonwealth of Massachusetts 4
City/Town of
System Pumping Record MAY 13 2p24
Form 4
L
DEP has provided this form for use by local Boards of Health. Other forms mAyr,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 bac si rear le right
A. Facility Information BUILDING: front back side rear leh right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab 04u(\QC41
key to move your Address
cursor-do not 1y`'
use Ilse return MA � !�"✓r�
key. Cilyrrown Stale Zip Code
2. System Owner.
r�
Name
rrnm
Address (if different from location).
MA
Cityrrown Slate Zip Code
Telephone Number
B. Pumping Record ff
1. Dale of Pumping o�eGLz — 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4• Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi 1.01' component pu ped:
erm
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7• an where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) pale
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