HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 132 CRICKET LANE 8/26/2024 IL
Commonwealth of Massachusetts Taal
City/Town of
�° System Pumping Record ��
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 :he pumping date in
accordance with 310 CMR 15.351.
HOUSE: fron back side rear 0right
A. Facility Information BUILDING: back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, _ `cl_
use only the tab 1 q,� /-��6'
key to move your Address
cursor-do not
use the return )j • 1�4NLQ,� MAH�—
key. Cllyfrown Slate Zip Code
2. System Owner:
Names
r
/NW/1
Address (if different from location)
MA
Clly/Town Slate Zip Code
Telephone Number
B. Pumping Record ,�✓�
Date of Pumping Da�` 13 2 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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E a�1AD31Z
Name Vehicle License Numbe
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
IltGL,5b
SignatJe of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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