HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 BANNAN DRIVE 10/24/2023 Commonwealth of Massachusetts
w City/Town of
System Pumping Record TO
Form 4 OL
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: front 55c
side rear left right
A. Facility Information BUILDING: front side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab -�&
key to move your Address� (
cursor-do not I V /�^, MA
use the return City/Town State 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 J� ------ 2 Quantity Pumped. ions
Date . Gallons
3. Component. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —,( —- —
4 Effluent Tee Filter present? ❑ Yes I/I No If yes, was it cleaned? ❑ Yes ❑ No
5 Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 58 Mass 1AA95E
Name Vehicl k=y
umber
Bateson Enterprises, Inc. _
Company
7, ion where contents were disposed:
GLSD _
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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