HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 CEDAR LANE 7/3/2023 <�N Commonwealth of Massachusetts
w City/Town of
a System Pumping Record ,U` �3�023
{ 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 your
local Board of Health to determine the form they use. The System Pumping.Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM 15.351. - -
HOUSE: front bac side rea le right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. Seem Cat n: G
on the computer, (/J� IC`^�'
use only the tab
key to move your Adgiress
cursor-do not J 7lQ ta,-,Ad 4 ,(
use the return City/Town
key. Stale Zip Code
2. S ste Owner:
aA f
a e
rciwn '
Address (if different from location)
City/Town . State Zip Code
yl_
Telephone Number
B. Pumping Record
1. Date of Pumping D _ 2ate . Quantity Pumped: Gallons�
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank g ❑ 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. Location where contents were disposed:
GLSD
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc 11/12 System Pumping Record•Page 1 of 1
