HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 SUTTON HILL ROAD 11/21/2023 Commonwealth of Massachusetts
tity/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 C M R 15.351.
A. Facility Information
Left/Right front of house, Left/ Right rear-of house, Left/ e of house, Under[
Important:When filling out forms �em Location: Left/Right side of building, Left/Right front of building, Left/ t rear f building,
1.
on the computer,
use only the tab
key to move your A dress 4
cursor-do not �, NL//1�1 MA ` b
use the return City own State Zip Code
key.
2. System Owner
ame
ixan
Address(if different from location)
MA
City/Town State O� � Zip Code
' _Telephone Number
B. Pumping Record
1 Date of Pumping ate 2 Quantity Pumped. allons
3. Component: ❑ Cesspool(s) iseptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): - —- —
4. Effluent Tee Filter present? ❑ Ye If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
KM
6. System Pumped By:
Dave Tiney Mass F5 1 �1644�95
Name Vehicle Lice a umber
Bateson Enterprises, Inc.
Company
7. Loc where contents were disposed:
LS —
Signature of Hauler Dat
Signature of Receiving Facility(or attach facility receipt) Date
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