HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 79 ROCKY BROOK ROAD 1/23/2024 � Comm " °���,0tth A°d°Ver onwealth of Massachusetts °W
City/Town of JAN 23 2024
System Pumping Record
Form 4
h �Qpa,��ent
DEP has provided this form for use by local Boards of Health. Other for 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: back side rear left right
Important:When DECK: under
filling out forms 1. System Loc tion:
on the computer, q l use only the tab GrL (bo'�
key to move your Ad ress
cursor•do not AA&-�—
use the return MA
key. City/Town State
Zip Code
2. System Owner:
„e �
Name
nnro
Address(if different from location) .
Cityrrown --- MA
State Zip Code
Telephone Number
B. Pumping Record pg
1. Date of Pumping c a rl 2. Quantity Pumped: �w
UatGallons
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 condition of component pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mass 1AA95E
Name Vehicle License Nu ber
Bateson Enterprises Inc.
Company
7. ion where contents were disposed:
GLSD
a
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
t5form4.doc• 11/12 \'
System Pumping Record•Page 1 of 1