HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 1/6/2023 Commonwealth of Massachusetts RECOVER
w r City/Town of _
System Pumping Record J04 p62023
Form 4 ToWN oRTH TMEVER
of N T
HEATH pEpAR
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 Syste.m 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: rout back side rear left i ht
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. Sys em Location:
on the computer,
use only the tab
key to move your A ress
cursor-do not J�
use the return Cit /Tow ' - - PTO-
key. OG
key. y State Zip Code
2. System Pner:
die
Name
iaarn —
Address(if different from location)
City/Town State
� Ziplode
Telephone Number
B. Pumping Record
1. Date of Pumping
p g Date 2. Quantity Pumped: cations
3. Component: ❑ Cesspbol(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:J/
�gy
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 Hauler j
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11112
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