HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 LOST POND LANE 10/2/2023 Commonwealth of Massachusetts
City/Town of
v o
a
System Pumping Record r' 1to
Form 4 �C
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 bac side rear left igh
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not ,I�nc�v MA
use the return City/Town State Zip Code
key.
2. System Owner:
,d 16ny uav,yPr _
Name
nnm
Address(if different from location)
_ MA
City/Town State��^ Zip Code
1113
Telephone Number
B. Pumping Record
1. Date of Pumping �\9 1Z 2. Quantity Pumped: �6
Date 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 Mas F5821 Mass 1AA95E
Name Vehicle umber
Bateson Enterprises, Inc.
Company
7. L tion where contents were disposed:
GLSD
b5C Ct 1,3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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