HomeMy WebLinkAboutSeptc Tank - Septic Pumping Slip - 32 CRICKET LANE 11/28/2022 Commonwealth of Massachusetts ��cE►vEc�
- City/Town of
System Pumping Record N0� 2g 2022
Form 4 TOWN pF NpRTHR MEN' a
SALIVA pEPPA
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 left right
A. Facility Information BUILDING: front ack side rear left right
Important:When DECK: under
filling out forms 1, System Location:
on the computer, `? �1 /fir i C� r l�
use only the tab "�j( C
key to move your Address �
cursor-do not
use the return key. Cit own State Zip Code
2. System Owner:
re y.
Name
reran
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping 2. Quantity /
Gallons
3. Component: ❑ Cesspool(s) �Septicank ❑ Tank Tight
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye �No 11'yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
A_yA17_(
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. on where contents were disposed:
GLSD
Signature of Hauler a Datel
Signature of Receiving Facility(or attach facility receipt) Date
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