HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 DUNCAN DRIVE 9/8/2026 tow
n of No over
Commonwealth of Massachusetts
SP 14 206
r City/Town of
System Purnping Record
' Forrn 4 � Partment
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 forrn 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: front backsl
u I t.D I fJ�: front back s i ci e- `ear
ear I e f�t r i g ht,
A. Facility Information f� rear left right
Important: When
DECK: under
(elliog out forms 1. Systern Location
on the computer,
use only the tab
key to move your Address -- - - -
cursor-do ncrl
use the return _.___...._.--__.._-- __ -- _ ._._.. _.. _ MA
key.
City/Town State Zip Code
J�
-- 2. Systern Owner:
r
Marne
�rnvn-•� ,�-
Address (if different from location)
MA
City/Town state Zip Code
' -p._..._.—.... ----- -.-.-_-_---------- _-...._...............
Telephone Plumber
L�. Pumping Record
1. Date of Pumping -.--__,__... ._.__...---...___. 2. Quantity Pumped:
Date Gallons
3. Component: Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease `trap
❑ Other (describe): __.___.__._...___..___.___..____._____
4. Effluent Tee Filter present? ❑ Yes a,,'No if yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped
G. stem P�ampc�d Fay:
C1ave 71nE M(1cle
ss 1AA95E Mass 1AD31Z
_. .___. _.-._._.._._ _.._.. V t_icensr Number
Bateson Enterprises, Inc.
Company
D ---.-re.
7. ��p lion where Conte is we disposed-
Signalure of Hauler Date
Signature of Recelving'hacfiity(or attach facility recr 1pt) Date
t5form4.doc• 11f12 System Pumping Record - Pale 1 ()f 1