HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 109 SAW MILL ROAD 5/8/2023 Commonwealth of Massachusetts �Ec�tvEo
City/Town of
System Pumping Record � �y �.W04'Dove�
{ Form 4 SOWN OF N9iVi PAI� O
H
ep
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
local Board of Health to determine the form they use. The Syste.m Pumping.Record must be submitte
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 ack side rea left rif
A. Facility Information BUILDING: ront back side rear left ri@
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, p\ I I
use only the lab �`�� _ (1, ►l� ` __
key to move your A dress
cursor•do not C �
use the return key. City/Town State Zip Code
2. System wnLr:
4�
�� 400,
Name
mwn r '
Address (if different from location)
City/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Yale 2. Quantity Pumped: �5
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 component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ation where contents were disposed:
GLSD
Signaturere of Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc 11/12 System Pumping Record•Page 1