HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ORCHARD HILL ROAD 5/13/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
41y y.,s
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. ------
HOUSE: front back side rear left right
A. Facility Information BUILDING: front back sid rear left ig t .
Important:When DECK: under
filling out forms 1. System Location:
on the computer, / - 6
use only the tab
key to move your Ad er SS V (� (*A MA 4/�( �`7
cursor-do not VDM
use the return City/Town State Zip Code
key.
2. S s m Owner:
Name
man
Address(if different from location)
MA
City/Town State Zip Code
Telephone Number
B. Pumping Record
v5c,
d
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 04io If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney _Mass 1AA95E ass 1AD31Z
Name Vehicle License Num
Bateson Enterprises, Inc.
Company
7. Locat' where contents were disposed:
LSD
Signature of Hauler Date—
Signature of Receiving Faci►ity(or attach facility receipt) Date
t5form4.doc•11/12 System Pumping Record•Page 1 of 1