HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 213 CARLTON LANE 8/26/2024 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 t%6d,'but the
information must be substantially the same as that provided here. Before usinglh'fs form, check with your
local Board of Health to determine the form they use. The System Pumpim�`Record must be submitted to
the local Board of Health or other approving authority within 14 days from -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rea61e right
A. Facility Information BUILDING: back side rear left right
Important:when DECK: under
filling out forms 1. System Locatio
on the computer,
use only the lab
key to move your Address
cursor return
not a►V �V MA ��j� lC
use the return Clt (Town
key. Y Stale Zip Code
IQt
2. System Owner:
e16 t CC% lko
Name
reran
Address (If different from location)
MA
Clly/Town State Zip Code
0%_�2 -2 fr3d
Telephone Number
B. Pumping Record
` {r
1. Date of Pumping Dag Ifs I 2. Quantity Pumped: K—f
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 com onent pumped: /
t n-A�
6. System Pumped By:
Dave Tiney Mass 1AA95E ass 1AD31Z
Name Vehicle License Num
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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