HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 CRICKET LANE 12/13/2021 Commonwealth of Massachusetts
City/Town of
i 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 house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer, A� `_�
use only the tab /` ye// /�f
key to move your Address cursor-do not MA
use the return
key. Cityfrown State Zip Code
2. Systefn Owner:
Na e
renm
Address(if different from location)
_ MA
Cityrrown Stat
Zip qode
Telephone Number —'�—
B. Pumping Record /
1. Date of PumpingJ�
D to 2. Quantity Pumped: Gallons -
3. Component: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------ _
4. Effluent Tee Filter present? ❑ Yes 4A—/,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�LwLhoere ents were disposed:
ste Water
Signature of Hauler Date