HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 BRIDGES LANE 7/17/2023 Commonwealth of Massachusetts N�
City/Town of
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System Pumping Record �N 1A
Form 4 N
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.
A. Facility Information
Left/Right front of house, Left/Right rear of house, Left Right ide of house, Under C
important:when Left/ Right side of building, Left/Right front of building, Left/ ig t rear of building,
filling out forms 1. System Location: g g, g g
on the computer,
use only the tab
key to move your Address
cursor-do not t'� Nfssc'61'� MA
use the return City/Town/Town State Zip Code
key. y
2. System Owner:
Uss ( oO
Name
iercm
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
'
Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
I
5. Observed conditi�n of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 IMIA A4/59
Name Vehicle License D umber
Bateson Enterprises, Inc.
Company
7. L cation where contents were disposed:
GLS
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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