HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 86 SHERWOOD DRIVE 11/21/2023 �N\
Commonwealth of Massachusetts
r City/Town of
a
System Pumping Record Vt1ti0tiu
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 le right
A. Facility Information BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer, � 5 �
use only the tab
key to move your Addre s
cursor-do not 1) ��UeT MA Qr
use the return
key. Cityrrown State Zip Code
4:1 2. System Owner:
Name
Address(if different from location)
MA
City/Town State ee cZip Code
—l�� ��— O1�Z
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: - -
Date 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 omponent pumped:
�dr�4
6. System Pumped By:
Dave Tiney Ma F5821 Mass 1A_A_95E_
Name Vehic Licens umber
Bateson Enterprises, Inc.
Company
7. qion where contents were disposed:
Signature of Hauler Date —--
Signature of Receiving Facility(or attach facility receipt) Date
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