HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 TANGLEWOOD LANE 10/21/2024 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 -.he pumping date in
accordance with 310 CMR 15.351.
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important;When
DECK: under
filling out forms 1. System Loc on:
on the computer, (� TC�t �� qft
use only the lab 1,� ` ` ____
key to move your Ad ress ✓
cursor-do not �� � MA j� �
use the return CII /Town
key. y Stale Zip Code
2. S4-1
ern Oww er
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,� Name
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roan
Address (If different from location)
MA
Clly(Town State Zip Code
ql� (0�-7- 3oa3
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: �" O
Dalee Gallons
3. Component: ❑ Cesspool(s) Septic T nk ❑ Tight Tank ❑ Grease Trap
D/Olher (describe).
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condi I n of component pumped:
I�J
6. System Pumped By'.
Dave Tiney Mass 1AA95E Mass 1AD31Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company --- — —
7. Location where contents were disposed:
3LSD
Signature of Hauler Date
Signature of Recelving Facility (or attach facility receipt) Dale
15form4.doc 11112 System Pumping Record Page 1 of 1