HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 CHRISTIAN WAY 10/7/2022 Commonwealth of Massachusetts RECEtVEL,
u City/Town of
a
System Pumping Record OCT 072022
Form 4 -OWN H OF OR H
'G^M TNDOVEp
AR7ME
DEP has provided this form for use by local Boards of Health. Other forms may be us��, 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 back side ear'(10 right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, I /
use only the tab /// " 2r1��
key to move your Address /
cursor-do not /� V-ff C ��5
use the return key. City/Town State Zip Code
2. System Owner:
�'71rC1 `
rob �
Naniie
reiorn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 4septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - -
4. Effluent Tee Filter present? ❑ Yes XNO If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pump/o: �w/
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo on w re contents were disposed:
LSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1