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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 TIFFANY LANE 10/24/2023 Commonwealth of Massachusetts ` City/Town of ,�oti3 A System Pumping Record .�ti�` Form 4 ©K �M 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 leKriligz A. Facility Information BUILDING: back side rear le DECK: under Important:When filling out forms 1. System Location: on the computer, n r— use only the tab key to move your Address cursor-do not N N\�L�/ MA � use the return CitylTown State Zip Code key. 2. System Owner: .� )�,a-ce-/'\ Ncos ------ - Name rearm Address(if different from location) MA City/Town State Zip Code IR--5--(I - [ 4 Telephone Number B. Pumping Record � -r 1. Date of Pumping Date) 1 2. Quantity Pumped. Gail-5 � - 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: DfM� 6. System Pumped By: Dave Tiney Mass F5821 Mass 1AA95 Name Vehicle License Nu er Bateson Enterprises, Inc. Company 7. gtion where contents were disposed: Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc• 11/12 System Pumping Record•Page 1 of 1