HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 PHEASANT BROOK ROAD 9/19/2022 Commonwealth of Massachusetts
= City/Town of
a System Pumping Record
a
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 form, check with your
local Board of Health to determine the form
they
authoSit within 14 days Pumping
h e pumping dabe insubmitted to
the local Board of Health or other approving Y
accordance with 310 CMR 15.351. HOUSE: front back side right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, $ O �4 s ��•}— f d6 -A t ✓�'��
use only the tab Address
key to move your
cursor-do notG�,V Zlp Code
use the return City[Town State
key.
2. System Owner: 91Q21
Name
lawn
Address(if different from location
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
❑ ) Septic Tank ❑ Tight Tank ❑ Grease Trap
3. Compon
ent: Cesspool(s
❑ Other (describe).
4. Effluent Tee Filter present? ❑ Yes No �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. Location where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
System Pumping Record• Page 1 of 1
t5form4.doc• 11112