HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 43 JAY ROAD 12/5/2022 ICN Commonwealth of Massachusetts ��cEwEv
City/Town of _ �E� 052022
System Pumping Record A�covE
Form 4 XO\N N(�EPA�M�NT
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 r r left right
A. Facility Information BUILDING: front back side rear a right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, Lfs �y n�
use only the tab e`
key to move your Address
cursor-do not 0- A' oA(
use the return Cit /Town "` 1
key. y State Zip Code
2. System Owner:
Nas o Poc-nx k lieu
Name
mWn
Address(if different from location)
City/Town State
Zip Code
26� _ c(�
Telephone Number
B. Pumping Record
1. Date of Pumping t
p g Date ZZ 2. Quantity Pumped: �'S�
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g El Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes)A No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
�fM4
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L cinwhere' contents were disposed:
GLSignuler Date - - — - -
Signature of Receiving Facility(or attach facility receipt) Date - -- -- -
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System Pumping Record •Page 1 of 1