HomeMy WebLinkAboutSeptic Pumping Slip - 72 Patton - 10/31/24 - Septic Pumping Slip - 72 PATTON LANE 10/31/2024 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 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 CM R 15.351.
HOUSE: front(back )side rear left lhit")
A. Facility Information BUILDING: front b"ack 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 AdCss
cursor-do not
use the return MA
key, City/TownState Zip Code
2. System Owner:
t(A
u
4A Name
Address(If(if different from location)
MA
City/Town State Zip Code
ti
'T;Iephone Num-b--e-r
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
-'
3. Component: ❑ Cesspool(s) Septic Tank 7 Tight Tank ❑ Grease Trap
r-1 Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes E] No
5. Observed condition of component pumped:
bc>I"tv", �
6. System Pumped By:
Mass 1,AA95E "Mass 1AD3tZ-,
Name Vehicle License
Bateson Enterprises, Inc.
Company
7. Loc*on where contents were disposed:
Signature of Hauler Date
T16-na`tu,e--�f-fker-e— iv Facility(o-Ing,---r attach._- - facility receipt)-.--r-ec--) ----Date
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