HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 357 CANDLESTICK ROAD 7/1/2024 Z�" Commonwealth of Massachusetts
City/Town of
0
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Other forms may be used,btfThe
information must be substantially the same as that provided here. Before usi th.19 form, check with your
local Board of Health to determine the form they use. The System Pumplcord 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 right
A. Facility Information BUILDING: Pont back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, S! T i C., S -'\� q
use only the tab 1,e
key to move your Ad ress
cursor-do not ���
use the return MA ®1�SyS
key. CityrTown Slate Zip Code
2. System Owner:
„e k
1�e,\.
Name '
imm
Address (if different from location)
MA
Cityrrown Stale Zip Code
Telephone Number
B. Purrlping Record
1. Date of Pumping Date flo
2 1 2• Quantity Pumped: Gallons
s�
3. Component: ❑ Cesspool(s) I[J 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 Mass 1AD31Z
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
LSD
Signature of Hauler Dale
Signature of Receiving,Facility(orrattach facility receipt) Date
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