HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 CRICKET LANE 12/13/2021 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 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/Rrear of se, Left/right side of house, Left
Right side of building, Left/Right front of building Left
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Telephone Number
B. Pumping Record
1. Date of Pumping Date _ 2. Quantity Pumped:
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. Lo�whee nts were disposed:
GLte Water
Signature of Hauler Date