HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 220 CANDLESTICK ROAD 7/29/2024 Comm � ��,�� And
Commonwealth of Massachusetts " ��' 'a`'
C ity/Town of ,U1- 2024
a System Pumping Record
Form 4 mP,nt
a
PEP has provided this form for use by local Boards of Health. Other forms maybe 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: frori back side rear eft right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the lab 2-16 C S <c
key to move your Address /
MA
cursor• not
use the return ���n�{
key. Cityrrown Slate Zip Code
2. System Owner:
Name
/e1U71
Address (if different from iocalion)
MA
City/Town Stale
Zip Code
Telephone Number
B. Pumping Record �7
1. Date of Pumping t 't [21
p 9 Date 2• Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
IV�c r`4
6. System Pumped By:
Dave Tiney Mass 1AA95E Mass 1AD 1
Name Vehicle license Num er
Bateson Enterprises, Inc.
Company
7. nLiton where contents were disposed:
Signature of Hauler Dale
Signature of Receiving Facility(orattach facility receipt) Date
l5form4.doc- 11/12
System Pumping Record •Pale 1 of 1