HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 JAY ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record ,u� 032�23
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: ront back side rear leftQ
A. Facility Information BUILDING: front back side rear left rii
DECK: under
Important:When
filling out forms 1. System Location.
on the computer, t
use only the lab 1 C
key to move your ` A A dress
N
cursor-do not totJeC
use the return City/Town Slate Zip Code
key.
2. System Owner:
r
Name
mwn
Address (it different from location)
City/Town . State �` Zip Code
Ct �8- Q�-I;tvl
Telephone Number
B. Pumping Record 2-5 r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Tral
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned?//11 Yes ❑ No
5. Observed condition of component pumped:
"-C Msl
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. ro ti n where contents were disposed:
D
Signature cf Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
15form4.doc- 11f12 System Pumping Record Page