HomeMy WebLinkAboutSeptic Tank - Receipt - 67 CRICKET LANE 1/2/2024 Commonwealth of Massachusetts
4
r City/Town of
a System Pumping Record �aN
Forrn 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 Si rear(�ri
ight
A. Facility Information BUILDING: front back rearght
Important:When DECK: under
filling out forms 1. System Location:
on the computer, np 2 C C\(_�v (r\
use only the tab l
key to move your Address
cursor-do not
use the return _ MA
key. City/Town State
Zip Code
2. System Owner:
Name
nnm
Address(if different from location).
MA
Cityrrown State
Zip Code
-Telephone
Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
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�copditionc component pu �d��
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Num r
Bateson Enterprises, Inc.
Company
7. tion where contents were disposed:
GLSD
12 I� Z3
Signature o auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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