HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 CRICKET LANE 9/21/2023 1
Commonwealth of Massachusetts
w City/Town of
a
System Pumping Record �Ep It1��23
w 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 back�sidrear er
htA. Facility Information BUILDING: front back lht
DECK: under
Important:When
filling out forms 1. S st m Lo ation:
on the computer, r
use only the tab
key to move your A d /,/
cursor-do not MA �(C�
use the return ity/Town State Zip Code
key.
2. System Owner:
Ab 1/3 re
Name
earn
Address (if different from location)
MA
City/Town State �n/ A
n� Code — —
Telephone Nuumber (/,L/
B. Pumping Record
1. Date of Pum in "� 2. Quantit Pum ed: �— -
p g at y p Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?XSl Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped. TTT
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
40C
n w re contents were disposed:
LSD
ature of Haule Date ,ate
Sign
Signature of Receiving Facility(or attach facility receipt) Date
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