HomeMy WebLinkAboutSeptic Pumping Slip - Septic Pumping Slip - 315 CANDLESTICK ROAD 10/17/2024 Commonwealth of Massachusetts
City/Town of
s 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 horn. Roforn using this form, shook 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 16,361, .
_ on back side re le right
fr HOUSE:
A. Facility information BUILDING: froh back side rear left right
Important:when DECK: under
filling out forms 1, System Location:
on the computer, �^
use only Ilia tabJ. Zc:
key to move your Address
cursor-donor �� (yt,� ..- MA � C,'}
key, Clty/Town return Clty/Town State Zip code
Q� rrb
2. System Owner:
r` game
rrran f:r
Address(If different from location)
MA
Clty/Town State J Zip Code
)S �- ,)6(1
Telephone Number
1 � $
B. Pumping Record_._._..
1. Date of Pumping gate 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 Tlney Mass 1 AA95E °Mass 1 AD31
Name Vehicle License
Sateson Enterprises, Inc.
Company
7. t'doakon where contents were disposed:
G L S _
Signature of Hauler _ Date L:
Signature of Receiving Facility(or attach facility receipt) Cato
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