HomeMy WebLinkAboutPumping Record - Septic Pumping Slip - 37 CARLTON LANE 12/3/2024 Commonwealth of Massachusetts
G= yry City/Town of
x S m P-� yste umping 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 th<4t provided here. Before using [his form, check with your
local Board of Health to determine the form they use. The System Purnpincg Record roust be submiUed to
the local Board of t-Ieaith or other approving authority within 14 days from -he pumping data in
accordance with 310 CMR 15 351.
__._-_..__ __.._.. _ , ea„ Ie right
HOUSE runt back side r
A. Facility Information BUILDING: front back side rear left right
Important: When DECK: under
filling out forms 1 System Lo 'ation:
on the cornpular, ,)
use only the tab r
key to move your Ad less _._— —__-_---
cursor-do not / q�
use the return GI wn .._._ .._ �_1 .. _ _....
key, p Code
2. kse Ow ter
Address (if different from loca(lon)
M AI
C6t Y
n/Tow _State AN
lp Code
rels phone Cf ,
mber
B. Pumping Record
3e,
1, Date of Purnping _�__ _ -- 2 Quantity Pumped'.
bate Gallons
3. Cor-nponent: ( Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
(_ Other (describe),
4. Effluent Tee Filter present? [) Yes ; No If yes, was it cleaned? ❑ Yes (I No
5. Observed condition of component purnped:
5 Systern Pumped By
gave They Mass 1AAy5E Mass 1AD31Z
Name uehie,le l-Icense N6rnber
Bateson Enterprises, lnc.
Corl7pany
7. Location where contents were disposed:
G1-5D
Sign-ature of Hauler Date
Signature off ea iving f actlity(or attacii facility (eceipl) Date
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