HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 39 GRANVILLE LANE 3/15/2024 Commonwealth of Massachusetts
City/Town of MAR 15 ti024
System Pumping Record
Form 4 c- .t
DEP has provided this form for use by local Boards of Health. Other forms maybe 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 �Ieft
h
A. Facility Information BUILDING: front back side rear
Important:When
DECK: under
filling out forms 1. System Location:
on the computer, 2q ���V t"e In
use only the tab ✓ l _
key to move your Address, �� D ' (*
cursor-do not /�11 lA _�wv MA
use the return Cil /Town
key. y State Zip Code
Q2. System Owner:
�r Name U�\
roam t\
Address (if different from location).
MA
Cityrrown State Zip Code
G I'l C,1�
Telephone Number
B. Pumping Record
1. Date of Pumping Z I 2. Quantity Pumped: on
Date 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 condition of component pumped.
6. System Pumped By:
Dave Tine
Mass F5821 Mass 1 AA9
Name Vehicle License Nu ber
Bateson Enterprises, Inc.
Company
I
7, ion where contents were disposed:
GLSD
U
k Z I
Signature of Hauler Date
Signature of Receiving Facility(or attach facility receipt) Date
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