HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 SUGARCANE LANE 8/23/2023 Commonwealth of Massachusetts
N City/Town of �tioti3
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. ---
HouSE: Cfron ack side rear left Qright,A. Facility InformationBUILDING: front back side rear left
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, c
use only the tab 3 1 rC -
key to move your Address
cursor-do not A I � � MA
use the return City/Town State Zip Code
key.
rd
2. System Owner:
A ra^«r- ct
Name
renm
Address(if different from location)
_ MA
City/Town State Zip Code
5/GD
Telephone Number
B. Pumping Record �� 3
1. Date of Pumping Date 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 ❑ No
5. Observed condition of component pumped.
6. System Pumped By:
Dave Tin_ey Mas F582 Mass 1AA95E
Name vehicI icen Number
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
LSD - - — - ---
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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