HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 89 MARIAN DRIVE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record ��� 032flZ3
{ Form 4
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 System 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 back ide rear left ri
A. Facility Information BUILDING: front side rear left ri,
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab � �r
key to move your Address
cursor•do not VJl_ t�nCm1✓�� S Qt ��
use the return City/Town State Zip Code
key.
2. System Owner:
r cve �Sac•�Yc k S
Name
nlwn
Address (if different from location)
Cily/Town . State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date t� — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trai
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? ] Yes ❑ No
5. Observed co dition of component pumped:
�pr
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.CLS
n where contents were disposed:
tsc Its l23
Signature oT Ha ler Dale
Signature of Receiving Facility(or allach facility receipt) Date
15torm4.doc 11/12 System Pumping Record Page