HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 DEER MEADOW ROAD 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. Otter forms may 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 forrh 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
Righ s de of building, Left/Right front of building, Left/Right rear of building, Under deck
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return MA
key. Ci own State Zip Code
tm
2. Sy t Own :
-
mdun _
Address(if different from location)
MA
City/Town — — — State �j Zip Code
Telephone Number
B. Pumping Record �f_r —f
2 /
1- Date of Pumping 7
p g Da a . Quantity Pumped: � -
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): ------
4. Effluent Tee Filter present? ❑ Yes 4 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:
GLSDaofHauler
ell W to Water
Signatu Dat