HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 CRICKET LANE 11/28/2022 Commonwealth of Massachusetts �Ec�►v�°
w City/Town of pv 2$ 2022
System Pumping Record N
TVA
Form 4 TOWN OFNkoi A MOTER
HEALTH°
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 ack side rear left rlg
A. Facility Information BUILDING: front ide rear left
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, /
use only the tab /
key to move your Address
cursor-do not
use the return it own State Zip Code
key.
2. sysp
!2�pwn(cc,�
Name Y
rnuro
Address(if different from location)
City/Town State 6�1 9c) 00�
Telephone Number Zip` C
B. Pumping Record
1. Date of Pumping Li
Date — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye o If yes, was it cleaned? ❑ Yes ❑ No
5. Ob$erved Indition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ion where contents were disposed:
LSD
Signature of Haule Date
Signature of Receiving Facility(or attach facility receipt)
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