HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 PURITAN AVENUE 6/10/2024 �\ Commonwealth of Massachusetts ", ; �c��hAr�dover
w City/Town of
x System Pumping Record ��N 10 2024
a
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 date in
accordance with 310 CMR 15.351.
HOUSE: front ac side rearq1le
right
A. Facility Information BUILDING: front c side rearright
Important:when DECK: under
filling out forms 1. System Lo n:
on the computer, rr��
use only the tab V lzatio
key to move your Address
cursor-do not 1- , MA d y�use the return City/Town
key. State Zip Code
2. System Owner:
�. Name
V
Address(if different from location)
MA
Cltyrrown State Zip Code
T-�&:-Wq-65 K
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z 2. Quantity Pumped: /�a
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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z
Name Vehicle License Numb r
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLS
G
Sign of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Date
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