HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 91 FULLER ROAD 5/8/2023 7
Commonwealth of Massachusetts so-w o
City/Town of 3
System Pumping Record
{ Form 4 �
,co�,��o.
DEP has provided this form for use by local Boards of Health. OtherTlorms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with ye
.local Board of Health to determine the form they use. The System 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: front back side rear left rig
A. Facility Information BUILDING: front back side rear left righ
DECK: under
Important;When
filling out forms 1. System Location.
on the computer,
use only the tab
key to move your Address
cursor-do not A j �n� _ i/� C,
use the return key. City/Town State Zip Code
2. System Owner:
,w r
Name
nlwn
Address (if different from location)
City/Town . State Zip Code
Gjq- q70 'Co530
Telephone Number
B. Pumping Record
1. Date of Pumping Date2. 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 condit'on of component pumped:
�6r r►�.
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. tion where contents were disposed:
GLSD
Signatur of Hauler Date
Signature of Receiving Facility(or allach facility receipt) Date
t5form4.doc 11/12 System Pumping Record•Page 1 of
•