HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 OLYMPIC LANE 7/1/2024 Commonwealth of Massachusetts
City/Town of
oltipti�r
System Pumping Record
Form 4 0\
DEP has provided this form for use by local Boards of Health, Other forms mays#, seed, but the
information must be substantially the same as that provided here. Before Ain-g 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 ack side rear left Igh
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 040 V, _
key to move your Address
cursor.do not use the return 0,A,46u,, _ _ MA
y
�S
ke Cilyfrown Stale Zip Code
2. System Owner:
N Ie
rf Name
Address (if different from location)
MA
Cityrrown State Zip Code
( ` L/ '(/
Telephone Number'
B. Pumping Record
1. Date of Pumping DD 2. Quantity Pumped
aleGallons
3. Component: ❑ Cesspool(s) ISeptic 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:
tll�brN��l
6. System Pumped By:
Dave Tiney Mass 1AA95E: �1AD
Name Vehicle license Num er
Bateson Enterprises, Inc.
Company
7. lion where contents were disposed:
GLS
to _
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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