HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 70 BROOKVIEW DRIVE 10/24/2023 Commonwealth of Massachusetts
City/Town of
a System Pumping Record
w Form 4 OC
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 back side rear left igh
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, r
use only the tab �
key to move your Address
cursor-do not �(��y.l� MA
use the return --- — —
key.
Cit !Town Slate Zip Code
2. System Owner:
,.e
rc aM _ A
Name
nMn
Address (if different from location) —
_ MA _
City/Town State — Zip Code
_239=y Lrsjqs _-
Telephone Number
B. Pumping Record
1. Date of Pumping �O �" ---- 2. Quantity Pumped:
Dale Gallons
li 3. Component: ❑ Cesspool(s) [� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --I—- --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By.
Dave Tiney _ Mas F5821 Mass 1AA95E
Name Vehicl !tense umber
Bateson Enterprises, Inc. _
Company
7. rLS
on where contents were disposed:
— - ro Fv — --
Signature of FTauler Date
Signature of Receiving Facility(or attach facility receipt) Dale
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