HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 88 PHEASANT BROOK ROAD 10/24/2023 Commonwealth of Massachusetts
City/Town of V p
System Pumping Record ��°G
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. -T,....".
HOUSE: fron back ide rear left right
A. Facility Information BUILDING: front ack side rear left right
DECK: under
Important:When
filling out forms 1. System acation-
on the computer, P-C cc V t./ L
use only the lab O�-
key to move your A dresg
cursor-do not Ia�,�` MA
use the return City/Town Slate Zip Code
key.
2. System Owner
,e M �.•�'� - — - -
Name
Address (if different from location)
MA
Cityrrown - - - — -- — Slate C(e) - �Z' Code —
Telephone Number
B, Pumping Record
1. Date of Pumping /Dalee Gallons r� —--- 2. Quantity Pumped: /ns
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
S. Observed condition of component p mped:
6. System Pumped By:
Dave Tiney _ Mas F582 Mass 1AA95E
Name Vehicl Licens umber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
15form4,doa 11/12 System Pumping Record-Page 1 of 1