HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 MARIAN DRIVE 9/1/2023 L�_ Commonwealth of Massachusetts o4 16"
City/Town of S�Q
a
System Pumping Record
Form 4
�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 CMR 15.351
HOUSE: front Mack sideG 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 � C_� -
key to move your Address
cursor-do not , MA
use the return ity/Town State Zip Code
key.
2. System Owner:
Name — �
Address(if different from location)
_MA
City/Town State Zip Code
Telephone Number
B. Pumping Record 1
1. Date of g Date Gallons
Pumping 2. Quantity Pumped: /
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:
06 C c,^,\ - --- -- -
6. System Pumped By:
Dave Tiney Mas F5821 Mass 1AM5E
Name Vehicl License umber
Bateson Enterprises, Inc.-
Company
7. tion where contents were disposed:
LSD _ _ ---.--
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1