HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 71 WILLOW RIDGE ROAD 9/1/2023 Commonwealth of Massachusetts
w City/Town of TO-
System Pumping Record
a S
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 ack side rear eft right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, Q
use only the tab ' t '
key to move your AdVs
cursor-do not /\A MA G
use the return City/Town State Zip Code
key.
2. System Owner:
re5 �
\(-ec) In
Name
Address(if different from location)
MA
City/Town State Zip Code
56& -C,
Telephone Number
B. Pumping Record
1. Date of Pumping Z 2. Quantity Pumped. /0
Datee 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 Tiney Mass F5821 Mas 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc. -
Company
7. oc ion where contents were disposed:
GLS
a -
-Toy
Signature of Ha er Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record•Page 1 of 1