HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 268 RALEIGH TAVERN LANE 10/30/2023 Commonwealth of Massachusetts
City/Town of
aS 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 back side rear left right
A. Facility Information BUILDING: front back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, 9�
use only the tab
key to move your Address
cursor-do not �a�r MA
use the return _ _ __
key. City/Town State Zip Code
2. System Owner:
Name
atun
Address(if different from location) —
_ MA
City/Town State
Zip Code
C�o03Fs
Telephone Number
B. Pumping Record
1. Date of to Pum A0�2 2�
Pumping Date 2 Quantity Pumped: 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:
00�Mw`
6. System Pumped By.-
Dave Tiney Mass C582)1 Mass 1AA95E
Name VehicleNumber
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
M—hl
Signature of auler Date --
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1