HomeMy WebLinkAboutSeptic Pumping Slip - 184 Carlton - Septic Pumping Slip - 184 CARLTON LANE 10/7/2024 Commonwealth f Massachusetts
n o Massach et
City/Town of
a System Pumping Record
Form 4
a`
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 ask side rear right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling o.Lit forms 1. System Locat' n:
on tha'pomputer,
use only the tab CY
key to move your Address
cursor-do not ,�A MA
use the return key. CitylT'own State Zip Ueda
2. System Owner:
f�
Name .�
reGm
Address(if different from location)
MA
Cfty(T'own Stater Zip Code
Tele—done Number ' V
B. Pumping Record
1. Date of Pumping D to 2. Quantity Pumped; Gatlin
I
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tanis ❑ 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 Mass 1AD31
Name Vehicle License Nu ber
sateson Enterprises, Inc.
Company
7, tion where contents were disposed:
ref
S
Signature of Hauler Gate
Signature of Recelving Facifity(or attach facility receipt) Date
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