HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 27 OAKES DRIVE 10/30/2023 Commonwealth of Massachusetts
City/Town of
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: fron<21k side rear(2)right
A. Facility Information BUILDING: front back side rear left right
DECK: under
Important:When
filling out forms 1. System Location:
on the computer, �r14 QS
use only the lab t' R
key to move your Address \,,
cursor-do not ��&LIx ___ MA
Stale Zip Code
use the return city/Town
key.
2. System Owner: ��++r.a ► &I�\i-r�_ >iC7--S lot - — —
Name
Address fir different from location)
MA
y Stale .Zip Code
Cil /Town T_? .�=10�1 I _Ttinc 4
Telephone Number
B. Pumping Recordat
2. QuantityPumped:
1. Date of Pumping Dale 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. Observed condition of component pumped:
i
6. System Pumped By:
j Dave Tines _ Ma s F5821 Mass 1AA95E
i Name Vehi le Licens Number
Eiateson Enterprises, Inc.
Company
7. L ion where contents were disposed:
GLSD _ ---
�` Signature of Hauler Dale
I - _
Signature of Receiving Facility(or attach facility receipt) Date
i
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