HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 VEST WAY 11/21/2023 Commonwealth of Massachusetts
w City/Town of
a System Pumping Record � 1
, Form 4 N
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: fron back side rear �Ieftrig
�ht
A. Facility Information BUILDING: back side rear
Important:When DECK: under
filling out forms 1. System Locatio
on the computer, c>q
use only the tab (
key to move your Add ess
cursor- not C MA
use the return
urn
key. City/town State Zip Code
reb 2. System Owner:
Name -
mrun
Address(if different from location)
- - — —
MA _
Citylrown State Code
Telephone Number
B. Pumping Record ,
1. Date of Pumping ��f 3-I - -
p g 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:
PjI)rl_A
6. System Pumped By:
Dave Tiney Ma F5821 Mass 1AA95E
Name Vehi Lice umber
Bateson Enterprises, Inc.
Company - - - - --
7. On where contents were disposed
---- - IG Z
Signature of Hauler Date
Signature cf Receiving Facility(or attach facility receipt) Date
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