HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 REA STREET 9/19/2022 Commonwealth of Massachusetts ijeGE,vEv
City/Town of
a
System Pumping Record SEP 192022
Form 4 t4oBl"ANDOVEVk
TOW,..��N pOF EpARTMENT
DEP has provided this form for use by local Boards of Health. C9t71etr 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: (fmnT�ack side real�fetight
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, nn
use only the tab r7C
key to move your Address
cursor-do not
use the return City/Town State Zip Code
key.
2. System Owner:
IaD i
Name
n(wn
Address(if different from location)
City/Town State Zip Code
1/7
Telephone Number
B. Pumping Record
1. Date of Pumping aa2. Quantity Pumped: lam,
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes /NNo If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of compo ent pumped:
[eye
i
i
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
{ Company
7. Location where contents were disposed:
GLS'D
I( ),elk
o2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1
i