HomeMy WebLinkAbout- Septic Pumping Slip - 218 DALE STREET 10/7/2022 Commonwealth of Massachusetts RECEIVEL)
H City/Town of
System Pumping Record OCT 072022
Form 4 o►�,N O H'"'- ANDOVEk
EAI..T
AI 7-A4
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 back side rear)left r ht
A. Facility Information BUILDING: front back side l-e� left right
Important:When
DECK: under
filling out forms 1. S tern Location:
on the computer,
use only the tab D A( _ RQSy 7 �\ D ,11� S
I�!/l'�T
Sr-
key to move your Addres f - ,
cursor- et not -A t-71"h/�1—
use the return ity/Town State
Pi-
key. Zip Code
2. System Owner:
tab
Name
iemm
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 4/0 /-OX)
g Date 2. Quantity Pumped:
Ga ons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
9 ❑ Grease Trap
❑ Other (describe): — - -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
1-7 tf
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Signature of ler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12 System Pumping Record •Page 1 of 1