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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 105 BROOKVIEW DRIVE 10/24/2023 Commonwealth of Massachusetts City/Town of a 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. g HOUSE: fron back side rear left h A. Facility Information BUILDING: front back side rear left right DECK: under Important:When filling out forms 1. System Loca ion. on the computer, � use only the lab w key to move your Address c cursor•do not V p j�_,►i,Q� MA use the return Cily/Town Slate Zip Code key. 2. Syste Owner- Name � Ow — _ ,d Name Address (if diHerenl from location) _ MA City/Town Slat© Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Galion Date 3. Component: ❑ Cesspool(s) ILA 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 p roped. 6. System Pumped By: Dave Tines _ Ma s F5821 Mass 1AA95E Name VehicNqjjLAas.0f Number Bateson Enterprises, Inc. Company 7. where contents were disposed:otion 1 11 / _ Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Dale t5form4.doc- 11/12 System Pumping Record - Page 1 of 1