HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 LOST POND LANE 5/2/2023 Commonwealth of Massachusetts RECEIVED
City/Town of t�igY 022023 .
System Pu�-nping Record
Form 4 TO HEWN
OF NORTH EP
LTH DEPARTMENT
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 tc
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 left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, ��\ %^ L '
use onlylythethe tab T
key to move your Addre s
cursor-do not �' � �4 — � ;��.i t
use the return City/Town State Zip Code ]—
key.
2. Sy �tem Owner:
uD
C
Name
iamn
Address (if different from location)
City/Town State Q� c Zip Code
Telephone Number B. Pumping Record
L1, Date of Pumping t 5 2. Quantity Pumped:
Dale Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4• Effluent Tee Filter present? ❑ Yes Z No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, on where contents were disposed:
GLSD
Z k
signature orHauler Date
t
Signature of Receiving Facility(or attach facility receipt) Dale
t5form4.doc- 11/12 System Pumping Record •Page 1 of 1