HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 79 MARIAN DRIVE 11/20/2025 Commonwealth of Massachusetts
y,1 City/Town of TO
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System Pumping Record r°
Sr>' Form 4
NOV 2 12025
DEP has provided this form for use by local hoards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Bef sd this form, check with your
local Board of Health to determine the form they use, The System Pu 1 c ubm•tted to
the local Board of Health or other approving authority within '14 days from the pt�l l gft 17
accordance with 310 CMR 15351.
___ HOUSE: front ac side rear left Ph
A. Facility Information BUILDING: front back side rear left rig;)t
important:when DECK: under
filling out forms 1, Systern Location.
on the computer, i
use only the tab
Rey to move your Address
cursor-do not MAuse the return _ _,._. __._,_._.. _._._._ .___._._ .. __ -_,_._ __.
Key. Zip Code
2. System Owner:
-
• r1 Name
Address(if different from location)
MA
Clty(Town St<of€ _
Gip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
. —
Date 2. Quantity Pumped.
Lallans
3. Component: [ Cesspool(, ) — Septic Tank (_� Tight Tank ❑ Crease Trap
Other (describe) _.___.. _._._ __ ____.__
4, Effluent Tee Filter present? [_� Ye No If yes, was it cleaned? [ ] Yes 0 No
5. Observed condition of component pumped;
-------------
3. System Pumped By:
Dave Ting Y --_-. _ ___ass 1 AAOU Mass 1 AD31 Z
acne Vehlcfe; l_ir,0r7aew urrrbe�r
Bateson Enterprises, Inc.
Cortlf>any
7, PLS
n where contents were disposed:
Signature of Hauler Date
Signature of facility rcceipC) Date
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