HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TURTLE LANE 7/1/2024 Commonwealth of Massachusetts
City/Town/Town of
= Y
a System Pumping Record
Form 4 ` �
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using 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 back side rear le right
A. Facility Information BUILDING: t back side rear left right
DECK: under
Important:When
filling out forms 1. S S7@Ill L tl0n:
on the computer,
use only the tab
key to move your dd ss�
cursor-do not MA
use the return l 0 &A
key. ity/Town State Zip Co e
2. System Owner:
Name
rerun
Address(if different from location)
MA
City/Town State 1�pCe
Telephone Number
B. Pumping Record
aL
1. Date of Pumping Date 2 Quantity Pumped: G llons
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 Mass 1AD 1Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. Location where contents ere disposed:
------- I /-
GLSD
Signatu Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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