HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 SUGARCANE LANE 8/26/2024 NG.
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Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 Ela\0
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 -he pumping date in
accordance with 310 CMR 15.351.
HOUSE: 0' ",
back side rear left fight
A. Facility Information BUILDING: back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab `� S�LG�re
key to move your Ad ress
cursor-do not `
use the return Clt /Town f��6Vt/ MA C\�LK
key. y State Zip Code
2. System
�n�r:
r>b W
far Name
man
r
Address(if different from location)
MA
Cityrrown State Zip Code
C P- -1iq - (0yC(o
Telephone Number
B. Pumping Record
1. Date of Pumping Date 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 cond'tion of component p mped:
6. System Pumped By:
Dave Tiney ss 1 AA95E Mass 1 AD31 Z
Name V hicle License Nu er
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GL3D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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