HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 344 RALEIGH TAVERN LANE 3/15/2024 Commonwealth of Massachusetts
N City/Town of tip`L�
a
W° System Pumping Record
w Form 4 '� �r
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.
A. Facility Information
Left/ Right front of house, Left/Right rear of house( Left Ri ht side of house, under C
Important:When Left/ Right side of building, Left/Ri ht front of builds Right rear of building,
filling out forms 1. System Loca ion: g g g
on the computer,
use only the tab
key to move your XAddrsscursor-do not MAuse the return own State Zip Code
key.
VkA
2. System ner
4�
Name
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Address(if different from location)
MA
City/Town StatueA _ � S7 Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date - 2. Quantity Pumped: 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 Tiney Mass F5<4 y� M 9 5�_
Name Vehicle Lice
Bateson Enterprises, Inc _
Company
7. Loc re contents were disposed:
LSD
Signatur r Date
lf
Signature of Receiving Facility(or attach facility receipt) Date
I
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