HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 CHRISTIAN WAY 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record s
{ 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, -HO•••
USE: front back side rear le ri,
A. Facility Information BUILDING: ont back side rear left ril
DECK: under
Important:When
filling out forms 1. System Location:S
on the computer, ss O �1 �n c y
use only the lab I �� l.C.!
key to move your
cursor•do not 1tt��.+►► �
use the return City/Town Slate Zip Code
key.
2. Systemner:
ue
Atcoyne
Name
ttlwn
Address (if different from location)
City/'Town. Stale Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �2'3 y p 2. Quantity Pum ed:
Date Gallons
3. Component: ❑ Cesspool(s) :Septic Tank ❑ Tight Tank ❑ Grease Tralz
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component p mped:
c rv�
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. lion where contents were disposed.
GLSD
Signature au er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5(orm4.doc 11112 System Pumping Record - Page