HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 TANGLEWOOD LANE 7/1/2024 Commonwealth of Massachusetts
_ C ity/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may b�" sed'but the
information must be substantially the same as that provided here. Befor" g•thls 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 CM 15.351,
HOUSE: front eside rear left right
A. Facility Information BUILDING: front back side rear left rrg t
Important:when DECK: under
filling out forms 1. System Lo tion:
on the computer, fan
use only the tab I
key to move your Address
cursor-do not � ) Nr>\ MA
use the return Cill frown
key. y Slate Zip Code
2. SystemOwner
c �u1ot
Name
reltm
Address (if different from location)
MA
Cltyrrown State Zip Code
Telephone Number
B. Pumping Record 1. Date of Pumping /n+
Date 2b 12,r{ 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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31
Name Vehicle license Nu ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GGLS � � Zy •
Signature of Hauler Date
Signature of Receiving Facility(orrattach facility receipt) Date
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