HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TIFFANY LANE 11/27/2023 Commonwealth of Massachusetts
City/Town of ��ti3
System Pumping Recordo� �
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 back side rear le righ
A. Facility Information BUILDING: ront back side rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the computer, q _
use only the tab � ( y t1l
key to move your Address A �
cursor- not (\ \ MA
use the return
urn Cit /Town
key. y State Zip Code
to
2. System Owner:
&Dt�\« Loa\S4-
y, Name
rerun 'y
Address (if different from location)
MA
City/Town State
Zip Code
`0 I0-
Telephone Number
B. Pumping Record
1. Date of Pumping r 116) 2') 2. QuantityPum Pumped: 1 a
Date
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:
�CM
6. System Pumped By:
Dave Tiney Ma F5821 Mass 1AA95E
Name Vehi Licens umber
Bateson Enterprises, Inc._
Company
7. on where contents were disposed:
GLSD
� 4-
SignatA of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date -
t5form4.doc•11/12 System Pumping Record•Page 1 of 1