HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 296 RALEIGH TAVERN LANE 7/1/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this for for use by local Boards of Health. Other forms l
e used, but the
information must be substantially the same as that provided here. Befor ingis 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(side rear le righ
A. Facility Information BUILDING: front back side rear left rt
Important:when DECK: under
filling out forms 1. System Loc tion:
on the computer, 1n/
use only the tab `L,-,-C' \ 1 �C.4�('(1
key to move your Address
cursor•do not 11`) Ny_\ _ MA
use the return own Cil !T
key. y State Zip Code
2. System Owner:
Name
roan
Address(if different from location)
MA
Cltyrrown State Zip Code
_ Telephone Number
B. Pumping Record
1. Date of Pumping S`�'�
2U 2 /
p 9 Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ Nc If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
& System Pumped By:
Dave Tiney _ Mass 1AA95E Mass 1AD31Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLS
Co- Z6 Z
SignalWof Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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