HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 10/2/2023 I'N Commonwealth of Massachusetts
City/Town of r\10, ®�tioti3
System Pumping Record
w 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.
HOUSE: front ack side rear left fight
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, rL n co n
use only the tab ��c.[ i\
key to move your A ress
cursor-do not , I ,�ovs/ MA Gk 2f/
use the return City/Town State Zip Code
key.
2. System Owner:
rd
Name
wren
Address(if different from location)
MA
Citylrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping bate 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 cc dition of component pumped:
P1oC!`ro��
6. System Pumped By:
Dave Tiney Mass F5821 Ma 1AA95E
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. 9tion where contents were disposed:
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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