HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 CROSSBOW LANE 5/31/2022 Commonwealth of Massachusetts '�ecewev
= City/Town of 22
System Pumping Record MAy 3120
��ANpOVER
Form 4 NOR NT
SOW�of A�-"DepAR�Me
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. HOUSE: front back si ear left ri
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, C)/
use only the tab (--,'l(J,� fiCJ"V •�
key to move your Ad re s
cursor-do not
use the return key. w Ci y on �Liwww��� State Zip Code
2. Sy em Owner:
Name
ie�mn
Address(if different from location)
City/Town State ip Code
ail-
Telephone Number
B. Pumping Record
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? ❑ Yes A
No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca here contents were disposed:
LSD
V- A Z
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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