HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 9/21/2023 Commonwealth of Massachusetts
City/Town of
3
a 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.
A. Facility Inform
Left Right nt of house, Left/ Right rear of house, Left/Right side of house, Under I
Important:When
filling out forms 1. Addss
m Location: Left/ Right side of building, Left/Right front of building, Left/Right rear of building,
on the computer,
use only the tab
key to move your
cursor-do not � � MA � _
use the return Citynown State Zip Code
key.
2. S stem Owner:
k"6
rd
Name
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping to - 2. Quantity Pumped: Gallons
3 Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - - - -- ---
4. Effluent Tee Filter present? ❑ Yews No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pum
6. System Pumped By:
Dave Tiney Mass F5821 ZMA 164 9'5Q
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Location where content were disposed.
GLSD
Signa auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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