HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 SHERWOOD DRIVE 4/19/2022 �ECENEd
Commonwealth of Massachusetts
City/Town of ppR 1 g 2022
a System Pumping Record DA-fHANOGVE�
Form 4 TpHEp,�TH0EpARTI��ENT
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 your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Left/Right front of house, L /Right rear of house, Left/Right side of house, Under Deck
Important:When
filling out forms 1. S stem Loc ion: Left/Right side of buildin Left t front Ri f building, Left/Right rear of building,
on the computer,
use only the tab oo o4k
key to move your Addr ss / / ,
cursor-do not _ MA G� `1�
use the return key. City/Town State Zip Code
2. System Owner:
Name
rerom
Address(if different from location)
_ MA
City/Town State Zip Code
0 --
Telephone Number
B. Pumping Record V_ //_1. Date of Pumping D to ��-- 2. Quantity Pumped: �Ilons
`�G
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Grease Trap
❑ Other(describe): — 14
I�f" -- - -
4. Effluent Tee Filter present? ❑ Ye9"
If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company- ---- - ---—--
7. ca w ere contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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