HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 151 CARLTON LANE 4/8/2025 n
Commonwealth of Massachusetts To w
City/Town of
System Pumping Record APR 14,2025
Form 4
DEP has provided this form for use by local Boards of Health. Other forms m
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: ront �ack
dA. Facility Information BUILDING: TF6 t side rear left right
Important:When DECK: under
filling out forms 1. System Locati
on the computer, I—
use only the tab
key to move your Address
— ----- --- - —T- —__..__..._ — --..�..
cursor-do not MA
use the return
key. City/TownState Zip Code
2. System caner:
Name
Address(if different from Vocation)
MA
City/Town State Zip Code
-Telephone jNumber
B. Pumping Record
q f s-,. 121,5-
1, Date of Pumping - 2. Quantity Pumped.
t6 Gallons
3. Component: F7 Cesspool(s) Septic Tank El Tight Tank ❑ Grease Trap
❑ Other (describe); ---------
4, Effluent Tee Filter present? 7 Yes /I No If yes, was it cleaned? 7 Yes ❑ No
5, Observed condition component pumped:
6. System Pumped By:
Dave Mass 1AA95E 'Kass IAD��i
Name y Vehicle License Nurn
Bateson F-Merprises, Inc.__
Company
7 'on where contents were disposed:
GLS
_Ai 2
Signature of Hauler Date
Signature Receiving Facility(or attach facility receipt) Date
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