HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 114 VEST WAY 10/18/2022 Commonwealth of Massachusetts
r
City/Town of ;3ECEIVED
System Pumping Record
OCT 18 2022
Form 4
'P R ME ER
NT
DEP has provided this form for use by local Boards of Health. Other forrlT4EAWl TOWN OF NOu&j but the
information must be substantially the.sarne 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 sid rea left right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, If
use only the tab aj M—
��J�
key to move your Address�r�I V Cy
cursor- not
use the return
urn
key. City/Town State Zip Code
2. System Owner:
Ast
Name
ietwn
Address(if different from location)
City/Town State V6
�— � Z��ode
Telephone umber
B. Pumping Record ` J w
1. Date of Pumping r G ` CCX)
p 9 Date 2 Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yesml.o If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump d:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number --
Bateson Enterprises Inc
Company
7. Loc ere contents were disposed:
LSD
Signature of Haul Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record•Page 1 of 1