HomeMy WebLinkAboutSeptic Pumping Slip - 196 Carlton Lane - Septic Pumping Slip - 196 CARLTON LANE 10/7/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record i
2
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 16.351. —
HOUSE: front ac side rear left rig
A. Facility Information BUILDING: front bac side rear left right
important:when DECK: under a
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not
MA
use the return1�"t
key. City/Town State Zip Code j
2. System Owner:
ray o
--
Name
morn
Address(if different from looatlon)
MA
Cityrrown State Zip Code
(1� — 6&-u'G353
Telephone Number
B. Pumping Record
1. Date of Pumping ti 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:
B. System Pumped By:
Dave Tiney Mass 1 AA95E ass 1 AD31 Z
Name Vehicle License Numb
Bateson Enterprises, Inc.
Company
7. where contents were disposed:
rcVion
S
d �
Signature of Hauler Date
Signature of Receiving acillty(or attach facility receipt) Date
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