HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 46 SHANNON LANE 3/15/2024 Commonwealth of Massachusetts
City/Town of R 15 �014
System Pumping Record Ma
Form 4
IaV v
DEP has provided this form for use by local Boards of Health. Other fo Pmay 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: Oront
back side rear le right
A. Facility Information BUILDING: back side rear left rig t
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab �_ S crr�1 I h
key to move your Add ess
cursor-do not 1�J_A,q?0)ver—
use the return v MA (J) c r
key. City/Town State 1— --
Zip Code
2. System Owne
VQ .fie T I i►.n e
Name
nnm
Address (if different from location) .
City/Town MA
State Zip Code
Co0- 3 -1C)' 31��
Telephone Number B. Pumping Record
1. Date of Pumping D3 f r Z,` 2. Quantity Pumped: 5
I
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:
rVOf'MS
6. System Pumped By:
Dave Tine
y Mass F5821 Mass 1AA95
Name Vehicle License ber
Bateson Enterprises, Inc.
Company
7. L 'on where contents were disposed:
GLSD
:13::11 i12_y _
Signature of auler Date
Signature of Receiving Facility(or attach facility receipt) Date
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