HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 44 EQUESTRIAN DRIVE 11/21/2023 ,,a 0
Commonwealth of Massachusettsfl- = `'` ✓
City/Town of � \-)'
ti3
a System Pumping Record Np�
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: 'back rear left
Important:When
DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab ('JLl >r
key to move your Addres—�--
cursor- not fV`4,1- �/ MA 3��'-(-
use the return
urn Cit /Town
key. y State Zip Code
2. System Owner:
r� K)6q-"r 'I So"rr-o
Name
rerun
Address(if different from location)
MA
City/Town State rp Cede
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped:
Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tank Tight
g ❑ Grease Trap
❑ Other(describe): - -- - --- --
4. Effluent Tee Filter present? ❑ Yes Q� No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pu/mped:
omA -
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
ame Vehicle umber
Bateson Enterprises, Inc.
Company
7. ion where contents were disposed:
GLS
wr
Signatur of}iauler Date — _ —
Signature of Receiving Facility(or attach facility receipt) Date
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