HomeMy WebLinkAboutSeptic Pumping Slip - 55 Lost Pond - 11/21/2024 - Septic Pumping Slip - 55 LOST POND LANE 11/21/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
sw 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 15.351. -*
HOUSE: front back side rearCCeft )right
ro
A. Facility Information BUILDING: ront back side rear left right
Important:When DECK: under
filling out forms 1. System Loca ' )n:
on the computer,
use only the tab �;
key to move your Address
cursor-do not �j ,I()n C 0 C)-'�"' MA
use the return City[Town State Zip Code
key.
2. System Owner:
Address(if different from location)
MA
City/Town State Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: 7 Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ED Yes Q No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tjne Mass 1AA95E z1vlass 1AD317,
Name Vehicle License Num1z!L_
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
LSD
Pot"
Signature of Hauler �—
/11 L
--Date
_Signature of Receiving Facility—(or attach facility receipt}y -b-a—te—
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