HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 LACONIA CIRCLE 11/21/2023 Commonwealth of Massachusetts
City/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 CMR 15.351.
HOUSE: fron back ide 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,
use only the tab
key to move your Address
cursor-do not f `�► MA C-
use the return Cit /Town
key, y State Zip Code
2. System Owner. cc
rad 0c,n ze MkQn
t, NYrne
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Address(if different from location) -
MA
City/Town State L�. �7�n�d�
Telephone Number
-- - - -
B. Pumping Record q -
1. Date of Pumping -- - J�Z
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 condi ion of component p mped:
Porc►�c�
6. System Pumped By:
Dave Tiney Ma F582 Mass 1AA95E
Name Vehi le License umber -
Bateson Enterprises, Inc.
Company
7. k c on where contents were disposed
GLSD
Signature of Hauler Date —-
Signature of Receiving Facility(or attach facility receipt) Date -
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