HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 STONECLEAVE ROAD 1/2/2024 Commonwealth of Massachusetts
City/Town of
a 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 rear le right
A. Facility Information BUILDING: front back side rear le right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 2G qV_P_
key to move your Ad re s
cursor- not
use the return
urn MA
key. City/Town State
Zip Code
2. System Owner:
„n 1 l
Name
ntun
Address(if different from location) .
City/Town MA
State (1 ciip Code
Telephone Number B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: IS DO
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 conditi n of component pumped:
6. System Pumped By
Dave Tiney Mass F5821 Mass 1A 995
Name Vehicle License N tuber
Bateson Enterprises Inc.
Company
7. on where contents were disposed:
G SSD
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc-11/12
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