HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 140 VEST WAY 10/24/2023 Commonwealth of Massachusetts
b City/Town of Record
System Pumping
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 back side rea left right
A. Facility Information BUILDING: ront back side rear left right
DECK: under
Important:When
filling out forms 1. System Locatio�
c .on the computer, �i O t es c.
use only the lab "� - V �/
key to move your Address
cursor-do not &� MA
use the return -City/Town Slate Zip Code
key.
2. System Owner:
Name
Address(if different Irom location)
_ MA
Cityrrown State .Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping — r ------ 2. Quantity Pumped:
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�C clitio of component pumped:
6. System Pumped By.
Dave Tiney _ M a srF51 Mass 1AA95E
ce
Name Vehtcl ' umber
Bateson Enterprises, Inc.
Company
7. Qion where contents were disposed!
Signature of Hauler Dale
Signature of Receiving Facility(or attach facility receipt) Dale
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