HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 78 TANGLEWOOD LANE 1/2/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record �pN
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 ck side rear left right
A. Facility Information BUILDING: r back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer, r r
use only the tab {-� lCOL01 efkQrj C)rt—
key to move your Addrescur use
the
- et not 10 1 "Ll"Ov—
use the return I�/ MA
key. City/Town State
Zip Code
2. System Owner:
Na e
�enm
Address(if different from location) .
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I 2. Quantity Pumped: �S
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 conditio of component pumped:
ar�
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95
Name
Vehicle License Nu ber
Bateson Enterprises Inc.
Company
7. oc ion where contents were disposed:
GLSD
Signature of H uler �RF
Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc- 11/12
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