HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 26 LONG PASTURE ROAD 7/3/2023 Commonwealth of Massachusetts
City/Town of* cF��`;o� ti�ti3
System Pumping Record N� SO-
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: front back side rear left ri;
A. Facility Information BUILDING: front back side rear left ril
DECK: under
Important:When
filling out forms 1. System Location n
on the computer, \V
use only the lab F�
key to move your Address ` �
cursor-do not ��1�1 !_`c,
use the return City/Town Slate Zip Code
key.
2. System Owner:
v �h
Name
n�um
Address(if different from location)
Cilyrrown . State
Zip Code
Telephone Number
B. Pumping Record abb
1. Date of Pumping Date Gallons 2. Quantity Pumped: as
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:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7, lion where contents were disposed:
GLSD
vT
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
151orm4.doc- 11/12 System Pumping Record • Page