HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 RALEIGH TAVERN LANE 11/27/2023 Commonwealth of Massachusetts
City/Town of
a System Pumping Record
Form 4 �14v
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 sid rear right
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, ^n n 1e\�� ka_�
use only the tab (P�f— lY�. n
key to move your A d es
cursor-do not �o MA C)N l6 q! -
use the return own Cit !T
key. y State Zip Code
2. System Owner:
rb ry� , t
!J.'cc PnCL
Name
etun
Address(if different from location) .
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping
p g Date G 2 -- 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: /
6. System Pumped By:
Dave Tiney Mas rF5821 Mass 1AA95E
Name Vehicle icense tuber
- -- -
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
LSD
Signature of1lauler Date -
Signature of Receiving Facility(or attach facility receipt) Date -
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1