HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 10 STILES STREET 8/29/2022 Commonwealth of Massachusetts RECE►VEG
City/Town of AUG 2 9 2022
a System Pumping Record THANDOVER
Form 4 TOWN Of DEPARTMENT
wM 1 V&-
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: C�-o back side rear Q right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab 1
key to move your Address
cursor-do not . ►' nG�cx��-�" /Vl �}--
use the return - —----
key.
City own State Zip Code
2. System Owner:
Name
iewn
Address(if different from location)
CityfTown State Zip Code
'�O S_' 3 D
Telephone Number
B. Pumping Record
i
��- v
1. Date of Pumping Date 2. Quantity Pumped: nanons
—- U
3. Component: ❑ Cesspool(s) 0-'Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): --- - — - -
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observe o9n�dition f component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. bcal where contents were disposed:
GLS
---
Signature of Hau er Dat1a
- --
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1