HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 35 TIFFANY LANE 8/26/2024 Commonwealth of Massachusetts
_ City/Town of 6 ti01�
System Pumping Record �
Form 4 ' tt.
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 the pumping date in
accordance with 310 CMR 15.351.
HOUSE: Qrontback side rear le right\
A. Facility Information BUILDING: back side rear left rig t
Important:When DECK: under
filling out forms 1. System LLoti
` on the computer,
use only the tab ,
key to move your Ad Tess
cursor-do not I ^�_���� MA
use the return City/Town
key. State Zip Code
2. System Owner:
y" ,e r
Name
num
Address(If different from location)
MA
CltylTown Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2� 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ 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 lAA95E Mass 1AD31Z
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
7. Lo ation where contents were disposed:
OL
�1 Fs 15 Z
Signature o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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