HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CEDAR LANE 8/23/2023 Commonwealth of Massachusetts
= City/Town of tioti�
System Pumping Record
Form 4 Q'
�M
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 CM 15.351. -- --
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, (
use only the tab t ,
key to move your Address
cursor-do not _ MA
use the return key. City/Town State Zip Code
2. System Owner:
rah c p^
Name
---
Address(if different from location)
_ MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping D-4� NO--
ate `� 2. Quantity Pumped. 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 ElNo
5. Observed condition of component p mped:
6. System Pumped By:
Dave Tiney ManF58 Mass 1AA95E
Name Vehic License N ber
Bateson Enterprises, inc.
Company
7. tion where contents were disposed:
qGLSD t _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1