HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 15 NORTH CROSS ROAD 9/6/2024 fi
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K\ Commonwealth of Massachusetts
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 the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear eft ight
A. Facility Information BUILDING: front back side rear left right
Important:when DECK: under
filling out forms 1. System Location.
on the computer, 1L�
use only the lab 1J k) • (��5�
+ key to move your Address
cursor-do not C IV ��o s,J��� MA
1 use the return 1ow1 --- --- Stale key. Zip Code
r�
2. System Owner:
3& n 1 k t -&A .
1 Name
nwn
Address (if different from location)
MA
City/Town Slate
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z� 2 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe): ��11
4. Effluent Tee Filter present? ❑ Yes trNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi 'n of component pumped:
6. System Pumped By:
Dave Tiney M s 1AA95E Mass 1AD31Z
Name Ve umber
Bateson Enterprises, Inc.
Company
7. 1-peakion where contents were disposed:
LSD
Signature of Hauler Dale
Signature of Receiving Facility(orahach facility receipt) Dale
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