HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 STONECLEAVE ROAD 7/1/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be us �
information must be substantially the same as that provided here. Before usin gts'Dg�VWaok ith your
local Board of Health to determine the form they use. The System Pumpi amust be submitted to
the local Board of Health or other approving authority within 14 days from0umping date in
accordance-with 310 CMR 15.351.
HOUSE: front bac side rear left righ
A. Facility Information BUILDING: front side rear left riigTit
Important:When DECK: under
filling out forms 1. System,Location:
on the computer, c n t
use only the tab IS 1 J
key to move your Addres
cursor•do not N MA 1�H�
use the return CIt /Town
key. y State Zip Code
2, System Owner:
l�
�Q
Name
reltm
Address (if different from location)
MA
City/Town State �] Zip Code
G(Cf-2- T
_ Telephone Number
B. Pumping Record
1. Date of Pumping Date `2 2 2. Quantity Pumped: /
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
9 ❑ 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 1AA95EEMass31AD
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. Ncation where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility(orattach facility receipt) Date
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