HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TURTLE LANE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
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 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:�f�rontack side rear leftri;
A. Facility Information BUILDINGask side rear left ril
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the lab `7
key to move your AcKyssAA
cursor•do not /�,� ✓In� �( �C/�
use the return
State Zi
key.
City/Town p Code
2. System Owner:
,.d
Name
nrwn
Address (it different from location)
City/Town . Slate Zip Code
• G�� _6 ss-�ls�G
Telephone Number
B, Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease TraK
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
C c�
6. ' System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L lion where contents were disposed:
LSD
4 6hh3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
t5lorm4.doc• 11/12 System Pumping Record -Page "