HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 211 CANDLESTICK ROAD 7/1/2024 Commonwealth of Massachusetts
_ City/Town of
o
System Pumping Record
Form 4 00\
41 I Y
DEP has provided this form for use by local Boards of Health. Other for �rgiybe used, but the
information must be substantially the same as that provided here. Befor�sing 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 rear left' lght
A. Facility Information BUILDING: front bR side rear left
Important:When DECK: under
filling out forms 1. System Location:
on the computer, �(1 1
use only the tab 2,11 Cq 'es 'c-
key to move your Address
cursor•do not �j .gn�6tyQl MA
use the return City/Town
key. State Zip Code
2. System Owner:
ame
nnwn
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping al 1t�IZ� 2. Quantity Pumped: �ns
Date y p Gallons
3. Component: ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank/ g El 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 1AD3
Name Vehicle License Numb r
Bateson Enterprises, Inc.
Company
7. n where contents were disposed:
G LS D,Q'J��
lU 1 ro
Signature of Hauler Date
Signature of Receiving Facility(or'attach facility receipt) Date
15form4.doc• 11112 System Pumping Record •Page 1 of 1