HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 175 OLD CART WAY 11/21/2025 Commonwealth of Massachusetts
City/Town of
�T System Bumping Record
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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 C M R 1 5.3 51. =--------- -------- -
HOUSE: front
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A. Facility �rifOt"CTlatlOt,. _.____ BUILDING: front � e' rear left
back side ri fhi
rear left right
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B Pumping Record
1. Date of Purnping Dane --- - - _-.__ - ____.. 2. Quantity Pumped
Galfons_.__._..�--- .---._
3. Cornponent. ❑ Cesspool(s) ] tic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe) ---- ------------
4, Effluent Tee Filter present? 0 Yes �r'lo If yes, was it cleaned? ❑ Yes [] No
5. Observed condition of component pumped:
6 Sy:' ern .iirnped By:
Da e Li noMass 1AA95E ass 1AD31Z
Nar e ' Vehicle License Number
Bateson Enlerprises, Inc-,
Company
.7 L anon where contents were disposed
LSD
Signature of h-1auler Dal -- --__
Signature of Fleceiving F"ac-if ily (or attach facility (eceipt) Date
I5form4.doc- 11112 System Purnping Record - Page 1 of 1