HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 20 FULLER MEADOW ROAD 8/7/2023 Commonwealth of Massachusetts
City/Town of N�P��No ti0ti3
A System Pumping Record p�Go
a
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 Info___.tion
Left ight front of house, Left/Right rear of house, Left/Right side of house, Under t
Important:When a /Right side of building, Left/Right front of building, Left/ Right rear of building,
filling out forms 1. S stem Loca ' /
on the computer, G �p„ �J /Q
use only the tab �C7w`� v�
key to move your ress !('�/�
cursor-do not �� MA 6�S S
use the return Vf _own State Zip Code
key.
2. System Owner:
rd _
t*me
nnvn .
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record /5�
1. Date of Pumping ate - — 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) AS
eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ 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:
y
Dave Tine Mass F5821 4& 61 5Q
---
Name Vehicle License Vumber
ij
AtAnct
Bateson Enterprises, Inc.
Company
7. Lo her ontents were disposed
LS _
Signature of He
Date
Signature of Receiving Facility(or attach facility receipt) Date
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