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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 GRANVILLE LANE 11/27/2023 Commonwealth of Massachusetts N City/Town of System Pumping Record �� �1202� 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. A. Facility Information Left/Right front of house, Le Right ear of house, Left/Right side of house, Under E Important:When Left/Right side of building, Left/Rig t front of building, Left/Right rear of building, filling out forms 1. System Location: on the computer, use only the tab I Grit"-• �'- In key to move your Address cursor-do not k) uy- MA ©I&q 5- use the return CityfT nwo State Zip Code key. 2. System Owner: raD , Name nrum Address(if different from location) MA City/Town State Zip Code 0Sb&' Fs2- C2g� Telephone Number B. Pumping Record 1 Date of Pumping /hk 2. Quantity Pumped: �/M06 Date 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 pu ped: 00C/-x - -- 6. System Pumped By: Dave Tiney Mas F58 1 IMIA M 9/5'\ Name Vehicle 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.doc•11/12 System Pumping Record•Page 1 of 1