HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 EVERGREEN DRIVE 5/2/2023 �Ec�tvE�
Commonwealth of Massachusetts
C ity/Town of 0 9 2M
a System Pumping Record Mpy
a p�ilvi ANpOVER
Form 4 TO H��N pEPAaTMENT
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 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: fron bac side rear left igh
A. Facility Information BUILDING: front a.ck side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the lab C. 1Couex-A -e-er
key to move your Add s
cursor•do not Mil
use the return City/Town Stale Zip Code
key.
2. System Owner:
S &;N &MY
Name
ruwn '
Address (if different from location)
Cily/Town . Stale Zip Code
Telephone Number
B. Pumping Record
1, Date of Pumping Date 2. Quantity Pumped: Gallo
3. Component: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap
I /
❑ Other (describe):
i
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
Pot'rvta,
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. to where contents were disposed:
GLSD
AT-2dlZ�
I Signature of Hauler Date
y
Signature of Receiving Facility(or attach facility receipt) Date
I
i
I 15form4.doc- 11/12
I System Pumping Record •Page 1 of 1
i