HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 TANGLEWOOD LANE 4/24/2026 Commonwealth
of Massachusetts
w v City/Town of
System PumpingRecord
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 Phis 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 Location:
on the computer,
use only the tab
key to move your Address j
cursor-do not yvcx MA l ��
use the return rn key, CityfTown State Zip Code
2. Sy em Owner;
Name
r
laftyll '
Address (if different from location)
MA
CltyfTown State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Component: ❑ Cesspooi(s) �epflc Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4, Effluent Tee Filter present? ❑ Yes �No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tine Mass I AA95E Mass 1 AD31 Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GL3D
S' re of Hauler Date
Signature of ReceivingFacility (or attach facility (eceipt) Date
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