HomeMy WebLinkAboutSeptic Pumping Slip - 65 Sugarcane - Septic Pumping Slip - 65 SUGARCANE LANE 10/4/2024 1
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 some 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 15.361.
HOUSE: front back side rear le ri ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under '
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not b• (�n� MA
use the return City/Town State Zip Code
key.
2. System Owner:
rid
Name
ream
Address(If different from location)
MA _
Cltyrrown State zip Code
6p I.7 vh 1-T-
7elephone'Number �
B. Pumping Record
4
1. Date of Pumping 2
pbato Gallons
Z. Quantity Pumped:
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No It yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tlney Mass 1AA95Ej Mass 1AD317-
Name Vehicle Ucense N er
Bateson Entearises, lnc.
Company
7. eatton where contents were disposed:
G LS
Signature of Hauler Date
Signature of Receiving Facillty(or attach facility receipt) Date
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