HomeMy WebLinkAboutSeptic Pumping Slip - 232 Candlestick - 10/30/24 - Septic Pumping Slip - 232 CANDLESTICK ROAD 10/30/2024 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 CIVIR 15.351. D------ -HOUSE: fro0back side rearCjt� right
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A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location,
on the computer, q 4-ce� iest
use only the tab
key to move your Address
cursor-do not MA
C .
use the return
key. CityfTown State Zip Code
2. System Owner:
Name
Address (if different from location)
VIA
City/Town State CA c -cc zip-code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped. -d-allons
3. Component: ❑ Cesspool(s) Septic Tank F7 Tight Tank ❑ Grease Trap
r_1 Other (describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By.
Dave Tin Mass 1AA95E �s 1�AD 3&
Name Vehicle License Numb
Bateson Enterprises, Inc. ----------
Company
7. LSD
Signature where contents were disposed:
LSD
Sighat7re of Hauler Date
_ —
Signature of Receiving Facility(or attach facility receipt) Date
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