HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 OLYMPIC LANE 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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.
A. Facility Information
1. System Location: Left/ Right front of house, Left eight rear of house Left/right side of house, Left/
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
use only the tab
key to move your Address
cursor-do not
use the return ---— - ----
key. City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): -- — —
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.,
M-BATESON ENTERPRISES,INC. Vehicle License Number
111 ARGILLA ROAD
compA�IDOVER, MA 01810
7. Location whew contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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