HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 ROCKY BROOK ROAD 5/8/2023 7
RECEIVED
Commonwealth of Massachusetts
w City/Town of $2023
System Pumping Record MAC ANppVER
Form 4 T�WNOFNDEPPTMENT
HEATH
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 yc
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: frorit back side rear, left ri&
A. Facility Information BUILDING: (Ent, bask side rear eft righ
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, t (� V (b
use only the lab 1 �C� Xp[�
key to move your �Ad-ress
cursor-do not
use the return ` C:
key.
CityrTown State Zip Code
2. S stem Owner:
"Tr
Name
rrmrn
Address (if different from location)
City/Town . Slate /�Q Zip Code
1
1�_ W Iq ^ QQo
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 LS 2. Quantity Pumped: A*0
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 conditio of component p mped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, cation where contents were disposed:
GL; D
U
�1212�
Signature tTHauler Date
Signature of Receiving Facility(or attach facility receipt) Date
5(orm4.doc 11112 System Pumping Record-Page 1 of