HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 84 CANDLESTICK ROAD 11/27/2023 \ `%N
Commonwealth of Massachusetts
w City/Town of
a
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 -backs-ide rear left Grigh
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, Q-(� `
use only the tab (�-1 CgnC\es 11 tL
key to move your Addres
cursor-do not ��j�+\
use the return MA
key. City/Town State Zip Code
nb 2. System Owner:
6 k!% A S
Name
Brun
Address(if different from location)
_
City/Town MAState
Zip Code
y21 C
Telephone Number
B. Pumping Record
1. Date of PumpingV�_1-V IZ'3 -
Date — 2 Quantity Pumped: Gallons
Is
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 condit•on of component pumped:
6. System Pumped By:
Dave Tiney Mass 582 Mass 1AA95E
Name Vehicle OseassoNumber
Bateson Enterprises, Inc.
Company
7. an where contents were disposed.
r fi OtoT
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record-Page 1 of 1