HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 CEDAR LANE 7/1/2024 Commonwealth of Massachusetts
City/Town of
.�TIL System Pumping Record
er-
Form 4 ^�
DEP has provided this form for use by local Boards of Health, Other forms m I? ,' b'e�, but the
information must be substantially the same as that provided here. Before uaWthts 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 right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System L cation'
on the computer, Ce use only the tab IOCo
key to move your Ad ress
cursor-do not �dVe� MA
use the return key. City/Town State Zip Code
2. System wner:
Name
mwn
Address(if different from location)
MA
Cltyrrown State Zip Code
CO�' ?- 3T GI yj
Telephone Number
B. Pumping Record
1. Date of Pumping Date ' Z 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:
i
& System Pumped By:
Dave Tiney Mass 1AA95E M�1AD31Z
Name Vehicle License Nu er
Bateson Enterprises, Inc.
Company
7. oca n where contents were disposed:
GLSD
C9 2
Signs ure of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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