HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 OLD CART WAY 11/21/2023 Commonwealth of Massachusetts
w It System P of
Pumping Record �0
Form 4
M
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 bac side rear left right
Important:When
DECK: under
filling out forms 1. System Location.
on the computer, 12 i- 61� C-C �
use only the tab \Q5 �
key to move your Address
cursor-do not AA � c
use the return r" MA �6y�
key. City/Town State Zip Code
rah 2. System Owner:
1 \
n n Shaw
Name
rerun
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1 Date of Pumping Date '( 123 -- 2. Quantity Pumped: Z — -
Gallons
3. Component: Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe): - - - - - - -- -- --
4. Effluent Tee Filter present? ❑ Yes/
es No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney MaQF5821 Mass 1AA95E
Name 4himber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLSD J
-
Signature of Hauler Date -- -
Signature of Receiving Facility(or attach facility receipt) Date
- --
t5form4.doc•11/12 System Pumping Record•Page 1 of 1