HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 27 OAKES DRIVE 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 Inform' ation
1. System Location: Left/Right front of house, Left/ i ht rear of hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left g ear of building, Under deck
Address ri
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CityNrown State���
Telephone Number
B. Pumping Record
tO
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes lam'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System_ Pumped By:
.Q� F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati nrhere contents^were disposed:
G 06well t Wate
5ignVbjre Hauler(' Date
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