HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 33 CRICKET LANE 5/2/2023 y
Commonwealth of Massachusetts
TRUMM, City/Town of
System Pumping Record �� Ole-o0
{ Form 4 �O�Np�GyPQ�M
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DEP has provided this form for use by local Boards of Health. Ot�ef s may be used, but the
information must be substantially the same as that provided here. Before using this form, check with yo
.local Board of Health to determine the form they use. The Syste.m Pumping.Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - - - -
HOUSE: fron tCiDiide rear(z righ
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important:When
filling out forms 1. System Locatio
on the computer,
use only the tab
key to move your Address
cursor•do not )YXL
use the return key. City/Town State Zip Code
2. System Owner:
pr I
4c�r6t 110C1 JC,
Name 1
— ---------------
Wren
Address (if different from location)
City/Town . State Zi Code
• G �-�r •57�C5.3�22,
Telephone Number
B. Pumping Record
c 2
1. Date of Pumping Date Z6 ! 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(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 c mponent pumped:
Ot M�
6. ' System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
GLS
V� L
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc 11/12 System Pumping Record•Page 1 of