HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 FULLER ROAD 10/24/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms r�1ay 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 le right
A. Facility Information BUILDING: front back side rear le right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, q� K f fer
use only the lab
key to move your Iss
cursor-do not , (fe(— MA _
use the return Cityffown Slate Zip Code
key.
2. System Owner:
Name
Address (if different from location)
MA _ _ _
City/-rown State Zip Code
_ .509- I B_!5?bg
Telephone Number
B. Pumping Record
1. Date of Pumping Date A 3--- 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 condition of component pumped:
6. System Pumped By:
Dave Tine_ _ Ma F58 1 Mass 1AA95E
N ame Vent ticens Number
Bateson Enterprises, Inc. _
Company
7. tion where contents were disposed:
"U GL ()
f _ Tb V13 _ - ---
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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