HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 101 COLONIAL AVENUE 10/24/2023 L,v Commonwealth of Massachusetts
Ci
ty/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.
HOUSE: fron back side rear le right
A. FacilityInformation BUILDING: rout back side rear I�ri ht
g
Important:When DECK: under
filling out forms 1. System Location:
on the computer, ^ `
use only the tab to
key to move your Addres
cursor-do not _ _ MA _
use the return C tyfTown
key. State Zlp Code
dL
2. System Owner:
rd 1-
1'� —
Name
rtnm
Address (if different from location)
_ MA
City/Town State �- �^ ._Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping e �� —---- 2. Quantity Pumped: oa lo�
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 con d' ion of component p mped:
6. System Pumped By:
Dave Tiney _ Mass 58 Mass 1AA95E
Name Vehicle kZ2se umber
Bateson Enterprises, Inc. _
Company
7. oca on where contents were disposed:
GLSD
�6
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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