HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 CHRISTIAN WAY 9/21/2023 Commonwealth of Massachusetts
City/Town of -�N°�P x5
System Pumping Record
a �
form 4 S
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 Information
Left/Right front of house, (Left ight rear-of house, Left/Right side of house, Under[
Important:When
filling out forms 1. S st m L cation: 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 Address fi�# t
cursor-do not (/�JVQL� � /\ MA
use the return City/Town State Zip Code
key.
2. S s m Owner:
a e
rerom
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record _
Date of Pumping ate -C�-- 2. Quantity Pumped: Gaiio�s
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 purr ed:
6. System Pumped By:
Dave Tiney Mass F5821 ZAA IM 5Q
Name Vehicle License umber
Bateson Enterprises, Inc.
Company
7. Location where contents re disposed:
GLSD
i
Signature of>91ler D to
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1