HomeMy WebLinkAbout- Septic Pumping Slip - 30 JAY ROAD 12/5/2022 BECE1VEo
Commonwealth of Massachusetts
City/Town of DEC p 5 2022
a System Pumping Record �H0400VER
Form 4 SOHEA�.TH0EPARTMEt`T
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 le right
A. Facility Information BUILDING: ont back side rear left t
Important:When
DECK: under
filling out forms 1. System Location
on the computer, �6 c
use only the tab J c4
key to move your Address
cursor-do not �`�) y�
use the return City/Town�� O State, �5
key, Zip Code
2. System Owner:
C4,6 'Pr.\ S
►m OSos�
Name
re�mn
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date's ► 2Z 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Ye/Umped:
No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed conditi n of component
C tbw
6. System Pumped By:
Dave Tiney _ _ Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLSD
Sign ture uler Date Z
Signature of Receiving Facility(or attach facility receipt) Date
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