HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 48 PADDOCK LANE 12/13/2021 Commonwealth of Massachusetts
. City/Town of
b 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 you
local Board of Health to determine the form they use. The.System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of se, Left/right side of house, Left
Right side of/building, Left/Right front of building, Left/Right e�of building, Under deck
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key. City/Town State Zip Code
2. System Owner:
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Name
Stun
Address(if different from location)
MA
City/Town State _a Zip Code
Telephone Number C/7,•t�
B. Pumping Record
_1. Date of Pumping /7) / 2. Quantity Pumped: /
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ 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:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. Location where contents were disposed:
GLSD Awell Waste Water
SignaAVR Hauler Date