HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 10/30/2023 i Commonwealth of Massachusetts
City/Town of �pti3
tip- 0
System Pumping Record
w 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; fro back side rear left right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the comp uter,
%
use only the lab _0— c o _
key to move your Address
cursor- not �<<S�_____ MA _
use the return
urn own
Cit /T
key. y State Zip Code
2. System Owner:
S1 fh•e� Sv..--
Name
nMn
Address (if different from location) —
_ MA ____
City/Town State .Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
p 9 Date 2. Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Q� Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --(--- __
4. Effluent Tee Filter present? ❑ Yes �] No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed ondition of component pumped:
4.
6. System Pumped By:
Dave Tiney Mass 5821 Mass 1AA95E
Name Vehicl License 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
t5form4.doa 11/12
System Pumping Record-Page 1 of 1