HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 280 CANDLESTICK ROAD 8/26/2024 N�411
Commonwealth of Massachusetts
City/Town of
System Pumping Record �s� �`' ���
Form 4 ^1
DEP has provided this form for use by local Boards of Health. Other forms 6utly`,e01 lased, 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: front back side rear left fight A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location:
on the computer, 12�
use only the tab Ccr1C ec, t`�
key to move your Address
cursor•do notuse MA O
key.the return Cily/T'own State Zip Code
2. System Owner:
-_� Name
gran
Address (if different from location)
MA
Cltyffown State Zip Code
a?&•35S-S_of
Telephone Number
B. Pumping Record
1. Date of Pumping Date �2 2. Quantity Pumped: Gal onn
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:
tVA
6. System Pumped By:
Dave Tiney M s 1�95 Mass 1 AD31 Z
Name Ve cle I-Icense mber
Bateson Enterprises, Inc.
Company
7. cation where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(orattach facility receipt) Date
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