HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 TIFFANY LANE 10/12/2021 Commonwealth of Massaohusetts RECEIVED
: mm
City/Town of
System Pumping Recordw ► "'"",""'1D .
Form 4
DEP has provided this form for useoby 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.
A. Facility Information
1. System Location: Left/f ' ht front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left Mightfr6MMuildifig, Left/Right rear of building, Under deck
Address
city[rown (P ( state Zip code
2. System Owner. �S
Name
Address(if different from location)
cityr town Stater Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D_N0 If yes, was ft cleaned? ❑ Yes ❑ No
5. Condition of System: �� f✓�^� � n s � `l � �
6. System Pumped r.
='Y�-' � �G k F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
S Lowe LoweN Waste Water
Signiqe qt HAW Date
doc-06/03 System moping Record•Page 1 of 1