HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 CRICKET LANE 1/13/2021 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 forth,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 re ouse, Left/right side of house, Left
Righ side of building, Left/Right front of building, Le Right rear o building, Under deck
on the computer, —�
use only the tab (((���
key to move your Address cursor-do not y� �i
Ci n ��� MA Q �3 y
use the return !Town
key. 'City/Town State Zip Code
2. System Owner:
Klie C�(�SAS'
flame - - --—
Address(if different from location)
MA
City/Town State / l/� ��� Zip 96 Code
,32-
TelephC/onne'Number
B. Pumping Record
/Sac)
1. Date of Pumping Date 2. Quantity Pumped: Canons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - — -
4. Effluent Tee Filter present? ❑ Yes•A No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Jon Kirmil Mass F5_821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company _
7. Lo here contents were disposed:
GLSD owell Waste Water
Signature of Hauler Date