HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 BARCO LANE 3/15/2024 'C"\ Commonwealth of Massachusetts
City/Town of
System Pumping Record MP
Form 4 a 'i
DEP has provided this form for use by local Boards of Health. OtheY 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: ro back side rear left ri ht
A. Facility Information BUILDING: front back side rear left right
Important:When
DECK: under
filling out forms 1. System Location.
on the computer, `
use only the lab 11, _ w
key to move your Address
cursor-do not n MA t
use the return ,~y
key. City/Town Slate Zip Code
2. System Owner:
S;f - + '�f J, -
Name
re(un
Address(if different from location).
MA
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Gallons
2. Quantity Pumped: /
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. Observd cp co po nclition of nent pumped:
6. System Pumped By:
Dave Tiney Mass F5821 Mas�1AA95
Name Vehicle License N tuber
Bateson Enterprises, Inc.
Company
7. Loe4ion where contents were disposed:
LSD
� 2 Z2
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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