HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 45 TURTLE LANE 9/5/2025 Commonwealth of Massachusetts �bwn Of JV 00417d
Over
City/Town of
19
System Pumping Record SAP 2025
Form 4 ",aao pe
DEP has provided this form for use by local Boards of Health. Other forms may It
information must be substantially the same as that provided here. Before using this form, checftth 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: ack side rear oft )right�11-
A. Facility Information BUILDING: rant back side rear left right
DECK: under
Important:When
filling out forms 1. System Location,
on the computer, to 6
use only the tab
key to move your :Addr s
A WaZi ----------
cursor-do not
use the return MA
key. Lcity/i own State Zip Code
2. System Ownev�)
Name
Address(if different from location)
MA
State 4n, 7 ez*� c Y- a ) ,-�e7- ---------
Te— 7
lephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped'.
Date Gallon s
3. Component: ❑ Cesspool(s) [:�eptic Tank ❑ Tight Tank r7 Grease Trap
❑ Other(describe):
4, Effluent Tee Filter present? [] Yes No If yes, was it cleaned? ❑ Yes ❑ No
5, Observed condition of component ,pumped
......Pvmped By:
6. Sy m
s
ave Tiney Mass 1AA95E Mas 1AD31Z
Lame Vehicle., License Number
B.ate s
Bateson EE te9prises, inc. -------
7. Qcation where contents were disposed:
,-u
Signature of
GLSD
auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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