HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 84 SUGARCANE LANE 10/24/2023 -C-\ 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. —`-
HOUSE: front ack side re left right
A. Facility Information BUILDING: t back side rear a right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the lab
key to move your Addre s
cursor-do not MA —Z i a �1)
use the return -— —
City own Stale Zip Code
key.
2. System Owner:
Name
Address (if different from location)
_ MA __ _ _
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping l� �f- ----- 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. ObservFed��conditio�l of component p mped:
6. System Pumped By:
Dave Tiney —_ _ Mas F582' Mass 1AA95E
Name Vehicl umber
Bateson Enterprises, Inc. _
Company
7. ion where contents were disposed:
QLSD
Signat re o Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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