HomeMy WebLinkAboutSeptic Pumping Slip - 49 Paddock Ln - Septic Pumping Slip - 49 PADDOCK LANE 10/18/2024 Commonwealth of Massachusetts
City/Town of
o 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 CIVIR 15,351.
HOUSE: (�ironi"pack side rear le 'right
A. Facility Information BUILDING: 'front "back side rear left right
Important;When DECK: under
filling out forms 1. System L,Kation:
on the computer,
use only the tab
key to move your ATss
cursor-do not -0 o 6w— MA
use the return
key. City/Town State Zip Code
2. System Owner:
Name
-Address(if different-from-l-o--c--at-i-o-n-)-
MA
Cityrrown Zip Code
-*-i 2�- -7
'telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank El Tight Tank 7 Grease Trap
F-1 Other(describe):
4. Effluent Tee Filter present? Fj Yes No If yes, was it cleaned? M Yes F7 No
5. Observed condition of component pumped:
6. System Pumped By:
_Dave Tlniey Mass 1AA95E ,-Mass 1AD31-Z,\
Name Vehicle License N ber
Bateson Enterprises, Inc.
Company
7. Loc. 'on where contents were disposed:
GLk
ignature of Hauler Date
Signature of Receiving Facility(or attach Date
t5form4.doc-11112 System Pumping Record-Page 1 of 1