HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 SAVILLE STREET 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 w
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 CMR 15.351. -- --
HOUSE: rout back side rear le. . right
A. Facility Information BUILDING: fron back side rear right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, t;rtV
use only the tab c/,,RJ�,[ ( J�
key to move your Addrx V[
cursor-do not
use the return City/Town
key. State Zip Code
reb 2. %em Owner:
r
Name
rerwn r
Address(if different from location)
City/Town Sta
�7 �o-� � Zlp Code
1 emphon'e(Nummoer
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes L�,No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum ed:
I
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 H �er � Date
Signature of Receiving Facility(or attach facility receipt) Date —
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