HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 SOUTH CROSS ROAD 10/24/2023 Commonwealth of Massachusetts
VCity/Town of oti3
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 rear left right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location.-
on the computer, �✓C 1
use only the tab fps �C
key to move your Address
cursor-do not _ MA _ QW-0` _
use the return tylTown State Zip Code
key.
2. System Owner, `
Name
Address(if different from location)
MA
City/Town State � �^ _�� ^ Zip Coe -
Telephone Number
B. Pumping Record
1. Date of Pumping — 2. Quantity Pumped: �ai �
Date
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 pu ped:
6. System Pumped By:
Dave Tiney _ _ Ma s F5821 Mass 1AA95E
Name Vehic License mber
Bateson Enterprises, Inc.
Company
7. 'on where contents were disposed
(!7eA
GLSD I
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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