HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 37 OLYMPIC LANE 11/4/2022 IL\ Commonwealth of Massachusetts
City/Town of — �ECE�vE►
System Pumping Record Nov 42022
>� Form 4 VER
ANpO
OF NUBT p TMENT
DEP has provided this form for use by local Boards of Health. Ojt9iNt;�F Wy% used, but the
information must be substantially the.sarne as that provided here.Ifore 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 side rear a right
A. Facility Information BUILDING: front back side ar left right
Important:When DECK: Under
filling out forms 1. System Locatign:
on the computer, �/ L /YL
use only the tab
key to move your Ad ress
cursor-do not
use the return
key. City/Town State Zip Code
2. Sy tem Owne r
s
Name
mmn
Address(if different from location)
City/Town State vLR �l 1p Code
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 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
1 7. Loca
JWwhere contents were disposed:
LSD
3�
Signature of Hauler Date
I
I
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12
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