HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 LACY STREET 8/5/2024 �oJe�
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use b local Boards of Health. Other forms r�� t� ed, but the
information must be substantially the same as that provided here. Before ul�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: �ont'
back side rear le rightA. Facility Information BUILDING: back side rear left
Important:when DECK: under
Iflling out forms 1. System Location:
on the computer, ('
use only the tab C J
key to move your Addres
cursor-donot nt� MA
use the return
urn
key. Slate
City/rown - .
ZI p Code
2. System Owner:
��. f11"-1 Cc se
Name
roan
Address (if different from location)
MA
CIIy/Town Slate
Zlp Code
��& 243- �Y��
Telephone Number
B. Pumping Record
IL
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) f� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): /
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
6. System Pumped By:
Dave Tiney M s 1AA95E Mass 1AD31Z
Name Veh le License Nu ber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
(eQ
LSD
DIY, lzti
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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