HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 SHERWOOD DRIVE 4/19/2022 �Rec,eNED
Commonwealth of Massachusetts APR 19�022
City/Town of jjTVA cvE
° System Pumping Record SoWNo�DEpPA,MENT
Form 4 HEP,
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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, Left/ Right rear of house, Left of house, Under Deck
Important:When
filling out forms 1. yst m Lo on: Left/Right side of building, Left/Right front of building, Le Right rear o building,
on the computer,
use only the tab
key to move your dress r ,
cursor-do not .�l/L]�11� _ _ MA
use the return key. City/Town State Zip Code
r�
2. Sy tern Owner:
Name
ream
Address(if different from location)
MA
City/Town State Zip Code
'V3
Telephone Number
B. Pumping Record A 2'Co C
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? ❑ Yelo 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. L to here contents were disposed:
GLSD
Signature of er Date
Signature of Receiving Facility(or attach facility receipt) Date
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