HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 HAY MEADOW ROAD 11/21/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record �A,.2ati{
Form 4 ,Q�
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. FBCIIIty Information BUILDING: front side rear eft right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab
key to move your Address
cursor-do not MA
use the return Cit /Town O �y�
key. y State Zip Code
Q2. System Owner:
S�e(A-
Name
rerun
Address(if different from location)
MA
Cityrrown State Zip Code
-OCP 3�
Telephone Number
B. Pumping Record
1. Date of Pumping —
p g D 2 23 — 2. Quantity Pumped:
le
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 VehicI umber
Bateson Enterprises, Inc.
Company
7. ation where contents were disposed:
GL3
Signature of Pauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc•11/12
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