HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 178 BRIDGES LANE 8/26/2024 Commonwealth of Massachusetts
City/Town of _ �r�gS T%T'
System Pumping Record �U '�
Form
DEP has provided this form for use by local Boards of Health, Other form used, but the
information must be substantially the same as that provided here. Before s ng 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: front back sid rear 0. right
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 1 0
use only the tab l�d
key to move your Address
cursor-do not N Qr �/ — MA 41 �
use the return Cit !Town "V
key. y State Zip Code
2. System Owner:
rd
Name
reran
Address(if different from location)
MA
City/Town State Zip Code
09-- S^
Telephone Number B. Pumping Record
1, Date of Pumping D_ ?' 2. Quantity Pumped: Gallons v
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:
vrr�.
6. System Pumped By:
Dave Tiney Ma 1AA95 Mass 1AD31Z
Name Ve cle License umber
Bateson Enterprises, Inc.
Company
7. on where contents were disposed:
GLSD
Signature of Hauler Date T
Signature of Receiving Facility(or attach facility receipt) Date
15form4.doc- 11/12 System Pumping Record•Page 1 of 1
