HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 126 VEST WAY 10/31/2022 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record OCT 312022
Form 4
TOWN
OF NORTH LTH DEPARTMENT
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: front bac side rear le
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location,
the computer,
use
' �,
use only the tab (_(E,
key to move yourcur qip-�
use th - et notuse the returntokey.
State Zip Code
2. System Owner:
Name
ie�um
Address(if different from location)
City/Town
State Zip Code
T elephone Number
B. Pumping Record
1. Date of Pumping
Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank
ElTight Tank ❑ Grease Trap
❑ Other (describe): -- /
4. Effluent Tee Filter present? ❑ Yes/
es No
If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
IVaI'
6. System Pumped By:
Dave Tiney Name Mass 1AA95E
Bateson Enterprises Inc --
Vehicle License Number —
Corn pany —
7. Location where contents were disposed:
GLSD
Signa auler
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
System Pumping Record•Page 1 of 1