HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 209 BRIDGES LANE 12/4/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record
a �
Form 4
�M
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 ac side rear left right
A. Facility Information BUILDING: front side rear left right
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, r�
use only the tab x:F( �r��CE', ►�
key to move your Address
cursor- not / _ � � MA at Sq_use the return
urn Cit Town b J
key. State Zip Code
2. System Owner: i
rah �J-r A c—
Name
etun
Address(if different from location)
_ MA
City/Town State Zip Code
co1� �- �31
Telephone Number
B. Pumping Record
1. Date of Pumping i 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): —
4. Effluent Tee Filter present? Ye No If yes, was it cleaned? Yes ❑ No
l
5. Observed condition of component pumped.
t')6CMCI
6. System Pumped By:
Dave Tiney _ Maa Mass 1AA95E
Name Vehiumber
Bateson Enterprises, Inc. _
Company
7. non where contents were disposed:
JZ3
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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