HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 74 STONECLEAVE ROAD 11/21/2023 Commonwealth of Massachusetts
City/Town of ,
System Pumping Record ''°` v 112�
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 back side rear left right
A. Facility Information BUILDING: front back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer, qc( c
use only the tab ` J _Ae_ eck
key to move your V
sscursor- not
use the return
urn MA
key. CitylTown State Zip Code
VQ 2. System Owner:
Name
a2m
Address(if different from location) ----
MA
Cityfl own State —
Zip Code
_- Telephone Number
B. Pumping Record
1. Date of Pumping / -
Date 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 F5821 Mass 1AA95E
Name Vehicl License umber
Bateson Enterprises, Inc.
Company
7. oc ' n where contents were disposed:
GLSD
JI 3
Signature of Hauler Date
i
Signature of Receiving Facility(or attach facility receipt) Date
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