HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 BRIDGES LANE 10/2/2023 �1\_ Commonwealth of Massachusetts o�QPe� tioti�
f
City/Town of
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 Information — ---
Left/ Right front of house, Left ight rear of house, Left/Right side of house, Under Dec
Important:When
filling out forms 1. S ste Location: Left/Right side of building, Left/ Right front of building, Left/Right rear of building,
on the computer, � t[�
use only the tab --
key to move your Address / '
cursor-do not ;/� A/5il/—'� — -- MA — -- �use the return CityfTown State Zip Code
key.
2. ystem wner:
Name -- - -- ----
feNm
Address(if different from location)
MA
City/Town State ?m—berK4
Zip Code
Telephone
B. Pumping Record /L
1. Date of Pumping ate 2. Quantity Pumped: 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 A �}�5 �
Name Vehicle Licens umber
Bateson Enterprises Inc.
Company
7. ca I here contents wer disposed:
3_ - --- - - - -- -- Gyo� —-
Signature of Ha Date
Signature of Receiving Facility(or attach facility receipt) Date
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