HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 50 CHRISTIAN WAY 12/21/2023 Commonwealth of Massachusetts
H City/Town of � 61,
o 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: front back side ar left ht
A. Facility Information BUILDING: front back si e rear left right
Important:When DECK: under
filling out forms 1. System Location.
on the he tabcomputer, � r'`S l�
use onlythe tab
key to move your Address h
cursor-do not A 1 /` _ Ue/-
use the return /t/ /�1J� MA
key. City/Town State
Zip Code
r�
2. System Owner
Name
Bran
Address(if different from location) .
_ . MA
City/Town State
Zi Code
Cog l-(�Ar1 -01 �
Telephone Number
B. Pumping Record
1. Date of Pumping /2,(1 �3 y Pumped:
2. Quantity Pum Date Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No f yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name
Vehicle License N ber
Bateson Enterprises Inc.
Company
7. where contents were disposed:
(;jtion
ab
Signature of Hauler Date —
Signature of Receiving Facility(or attach facility receipt) Date
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