HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 30 SUGARCANE LANE 7/29/2024 Commonwealth of Massachusetts
_ City/Town of jU j- 2 9 NZ4
System Pumping Record
w 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: ront ck side rear le right
A. Facility Information BUILDING: ront back side rear left right
Important:When DECK: under
filling out forms 1. System Lopat
on the computer, (/J�)
use only the tabVT /� C4
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use the return ity/Town State Zip Code
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2. Syst tnbow
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Name /%L—
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Address(if different from location)
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City/Town State r�7;p�Cgde
Telephon Number
B. Pumping Record
1. Date of Pumping u/ 2. Quantity Pumped: /
Date Ga ons
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 s 1AA95E ass 1AD31Z
Name Vehicle License Nu
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD 14
454���
Signature of Ha Da
Signature of Receiving Facility(or attach facility receipt) Date
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