HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 RALEIGH TAVERN LANE 7/17/2023 '�!N_ Commonwealth of Massachusetts
= City/Town of
System Pumping Record
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 CMR 15.351.
A. Facility In forma
Left/ Right ront of house, Left/Right rear-of house, Left/ Right side of house, Under C
Important:When
filling out forms 1. System Location: Left/Rig t side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab
key to move your Address
cursor-do not ��� MA
use the return City/Town State Zip Code
key.
2. System Owner:
(.1-1,5 WoaI 6co.s k
Name
/NLCI!
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record -1
1. Date of Pumping pate 2'3 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) 11 Septic Tank ❑ Tight Tank El Grease Trap
❑ Other (describe): r
4. Effluent Tee Filter present? ❑ Yes Ld No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave TineY Mass F5821 AU }4%Tj'
Name Vehicle License gbber
Bateson Enterprises, Inc.
Company
7. . n where contents were disposed:
G SS D
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
I
t5form4.doc•11/12 System Pumping Record•Page 1 of 1